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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880992
Report Date: 09/02/2021
Date Signed: 09/02/2021 10:46:30 AM

Document Has Been Signed on 09/02/2021 10:46 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGELICUM RCFEFACILITY NUMBER:
331880992
ADMINISTRATOR:REYES, VIVIAN EFACILITY TYPE:
740
ADDRESS:112 ROMANZA LNTELEPHONE:
(224) 814-7022
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 5DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Vivian Reyes, LicenseeTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced annual inspection. LPA Gardner was granted entrance and met with Licensee Vivian Reyes. There are currently no cases of COVID-19 within the facility.

LPA Gardner inspected the facility and the following was observed: The home is one story, four bedroom, three bathroom home. There is a front living room, dining room, family room, kitchen, and a space used as an office. Towels, linens and hygiene products were observed in a closet and appeared to be in sufficient supply and quality for residents to use. The residents rooms were furnished with bed, dresser, chair and lighting for residents comfort. The residents medication and residents files are stored in a locked cabinet near the garage. The knives are kept in a locked box inside a drawer in the kitchen. LPA Gardner observed the kitchen to be supplied with adequate plates, cups, dishes and silverware, as well as pots, pans and serving bowls for residents use. The food supply was inspected and met the minimum requirement of 7 days non-perishable and 3 days perishable foods. The chemicals and cleansers are stored in the laundry room which is locked. The backyard is fully fenced and has chairs and shade for residents use.

LPA Gardner observed a sign in desk documenting visitor's temperature. There was sufficient hand hygiene supplies, and cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control.

During the inspection LPA Gardner discussed infection control practices and procedures with Ms. Reyes.

An exit interview was conducted and a copy of this report, was reviewed with and provided to Ms. Reyes
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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