331880992-10-21-2024-18-AS-SJEN-DA9PGH-20241021111822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880992
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:18:51 AM

Document Has Been Signed on 10/21/2024 11:18 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ANGELICUM RCFE		FACILITY NUMBER:	331880992
ADMINISTRATOR/ DIRECTOR:	REYES, VIVIAN E		FACILITY TYPE:	740
ADDRESS:	112 ROMANZA LN		TELEPHONE:	(442) 282-1126
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY: 6		CENSUS: 2	DATE:	10/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Vivian Reyes, administrator		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Seo Jeon, Andrei Castillo, and Ferrer Sabarias conducted an unannounced annual required visit. Upon entry, LPAs were greeted by Vivian Reyes, administrator, and informed them of the purpose of the visit. At the time of the visit, there were two staff members and two residents present.

Facility Overview: The facility is a one-story home with four bedrooms and three bathrooms, including an attached garage. There are no pools or firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Fire extinguisher located in the kitchen had current inspection tag. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 120°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Continued on LIC809-C....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELICUM RCFE	FACILITY NUMBER: 331880992
	VISIT DATE: 10/21/2024

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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate.

Record Review and Resident/Staff Files: LPA reviewed files for two staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Two resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. However, a staff's prescription medication bottles were stored in a drawer in the kitchen that was accessible to the residents in care. Citation was issued. LPA reviewed medications for two residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10-6-2024, which met department requirements. All facility exits were clear of obstructions.

One deficiency was cited during the visit. An exit interview was conducted, during which this report, LIC809-D and Appeals Rights were reviewed and provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2024 11:18 AM - It Cannot Be Edited

Created By: Seo Jeon On 10/21/2024 at 10:04 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELICUM RCFE	FACILITY NUMBER: 331880992
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Staff's prescription medication bottles were observed in a kitchen drawer that was accessible to the residents in care.
	POC Due Date: 10/22/2024
	Plan of Correction
1 2 3 4	Licensee immediately removed the medication bottles to locked cabinet. Licensee will send proof of staff training on importance of centrally stored medication by the above POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Seo Jeon

LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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