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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881472
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:47:33 PM

Document Has Been Signed on 10/01/2024 12:47 PM - 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:ANGEL HOMECAREFACILITY NUMBER:
331881472
ADMINISTRATOR/
DIRECTOR:		ROCHA, BERNARDAFACILITY TYPE:
740
ADDRESS:31555 AVENIDA DEL PADRETELEPHONE:
(760) 202-2312
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 3DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Joshua Rocha, licenseeTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Seo Jeon and Andrei Castillo conducted an unannounced annual required visit. Upon entry, LPAs were greeted by Joshua Rocha, licensee and informed them of the purpose of the visit. At the time of the visit, there were two (2) staff members and three (3) residents present.

Facility Overview: The facility is a one-story home with (6) bedrooms and (5) 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. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 116.7°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.

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

Continued on LIC809-C.....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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: ANGEL HOMECARE
FACILITY NUMBER: 331881472
VISIT DATE: 10/01/2024
NARRATIVE
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Record Review and Resident/Staff Files: LPA reviewed files for three (3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three (3) resident files were reviewed and contained all required documentation. Based on observation and record review, the facility does not have an approved fire clearance for bedridden residents. Two (2) of three (3) residents in care were identified as bedridden. Licensee did not ensure 2 out of 3 residents have current appraisals on file. Citations were issued.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for four 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. All facility exits were clear of obstructions.

Two (2) deficiencies were cited during the visit. An exit interview was conducted, during which this report, LIC809-D, LIC421IM and Appeals Right were reviewed and provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/01/2024 12:47 PM - It Cannot Be Edited


Created By: Seo Jeon On 10/01/2024 at 12:03 PM
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: ANGEL HOMECARE
FACILITY NUMBER: 331881472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, Licensee failed to comply with the fire clearance. The facility does not have an approved fire clearance. Facility is licensed for 6 non-ambulatory residents. 2 of 3 residents in care were identified as bedridden. This poses an immediate health and safety risk to residents in care.
POC Due Date: 10/02/2024
Plan of Correction
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Licensee/Administrator stated that they will submit an LIC 200 requesting to bedridden clearance along with required documentation by POC due date.
An immediate $500 civil penalty is being assessed. A $100 per day will continue until corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/01/2024 12:47 PM - It Cannot Be Edited


Created By: Seo Jeon On 10/01/2024 at 12:03 PM
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: ANGEL HOMECARE
FACILITY NUMBER: 331881472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not ensure 2 out of 3 residents have current appraisals on file. This poses a potential health and safety risk to residents in care.
POC Due Date: 10/15/2024
Plan of Correction
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Licensee/Administror, Joshua Rocha, stated they will complete all two appraisal and submit them by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024


LIC809 (FAS) - (06/04)
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