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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005870
Report Date: 02/22/2022
Date Signed: 02/22/2022 11:22:13 AM

Document Has Been Signed on 02/22/2022 11:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELIC DWELLING CARE HOMEFACILITY NUMBER:
306005870
ADMINISTRATOR:FAJARDO, RHOENAFACILITY TYPE:
740
ADDRESS:17709 BEECH STREETTELEPHONE:
(949) 413-3049
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 3DATE:
02/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Rhoena Fajardo - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Angelic Dwelling Care Home. The purpose of today's visit was a Plan of Correction to follow-up on the deficiencies issued during the Required 1 Year visit dated February 17, 2022. LPA Velazquez was allowed entry into the facility and met with Administrator (AD) Rhoena Fajardo. The following deficiencies were issued:

87303(i)(1)(A-C) Maintenance and Operation. (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. During the visit dated 02/17/2022 the facility did not have a signal system present which was verified by Caregivers Ana Millare and Gloria Oblefias. The plan of correction date was 02/18/2022. On today's visit Administrator Fajardo demonstrated the signal system purchased for the facility. The system has yet to be set up and LPA Velazquez will extend the POC due date to February 23, 2022. AD Fajardo will submit proof correction to LPA Velazquez.

87355(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. During the visit dated 02/17/2022 LPA Velazquez observed the caregivers present were not associated to the facility and 1 caregiver did not have fingerprint clearance. A civil penalty was issued. On today's visit LPA observed that 1 caregiver has been cleared and associated to the facility while the other caregiver no longer works at the facility. LPA and AD conducted a walk through and did not observe the other caregiver present.

An exit interview was conducted with AD Rhoena Fajardo and a copy of this report along with a copy of the clearance letter was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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