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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530240
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:57:57 PM

Document Has Been Signed on 12/04/2024 01:57 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLCFACILITY NUMBER:
335530240
ADMINISTRATOR/
DIRECTOR:		MAZARIEGOS, JOHNNYFACILITY TYPE:
740
ADDRESS:36785 BRAKEN WAYTELEPHONE:
(951) 452-1216
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 6CENSUS: 5DATE:
12/04/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator/Applicant Ricardo Garcia and Administrator Johnny MazariegosTIME VISIT/
INSPECTION COMPLETED:
01:58 PM
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On 12/04/2024 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for the purpose of a Change of Ownership evaluation. LPA met with Administrator/Applicant Ricardo Garcia and Administrator Johnny Mazariegos. An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 06/13/2024 for a total capacity of six (6). Fire clearance was granted on 05/17/2024 for four non-ambulatory and two (2) bedridden residents. LPA Brown observed the following:

Structure:
Facility was a one-level house with five (5) bedrooms, three (3) resident/staff bathrooms, living room, dining area, laundry room and kitchen. There was an attached car garage observed..
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house.
Bedrooms:
Each resident bedrooms accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The three (3) resident/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 09:45 AM, LPA tested the water temperature in the resident/staff shared bathrooms. LPA verified water temperature was measured at 108.6 degrees Fahrenheit. LPA Brown observed one resident/staff shared bathroom without non-slip mat in the bathtub/shower. Technical Assistance issued. During the visit, Administrator/Applicant Garcia purchased non-slip mat for one (1) resident/staff shared bathroom. Also, LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Technical Assistance issued. During the visit, Administrator/Applicant Garcia purchased the required night lights. ***CONTINUED ON LIC 809C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLC
FACILITY NUMBER: 335530240
VISIT DATE: 12/04/2024
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***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. There is more than seven (7) days’ supply of perishable foods and more than two (2) days’ supply of non-perishable foods. There was adequate seating for meals for all residents. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies are stored in the laundry room.

Living/Family room:
There was a living/family room with adequate seating for all residents and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Side gates on left side of the facility. All outdoor pathways were free of obstructions.

Dementia Care:
LPA Brown reviewed the facility’s Dementia Care Plan during the Visit.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted. There was Ombudsman poster and Let-Us-No poster observed. LPA Brown observed Personal Rights posted in a common area.

General items:
One (1) fire extinguisher was charged, smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the kitchen. First Aid kit missing a tweezer. Technical Assistance issued. Administrator/Applicant Garcia purchased tweezer during the visit. Locked area for medication storage was observed. ***CONTINUED ON LIC 809C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLC
FACILITY NUMBER: 335530240
VISIT DATE: 12/04/2024
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***CONTINUED FROM LIC 809C**

LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 951-246-0026. Infection Control Plan and Emergency Disaster Plan observed at the facility. Expired emergency food observed and no emergency supplies maintained at the facility. Technical Assistance issued. Administrator/Applicant purchased emergency food and stated to obtain and prepare emergency supplies during the visit. Component III was completed on this day as well.



However, LPA Brown observed Staff #2 (S2) working at the facility but per documents review, S2 was not associated to the facility. Applicant/Administrator Garcia reported to LPA Brown that S2 started working at the facility on 09/2024. Also, LPA Brown observed Staff #1 (S1) criminal background clearance was not transferred to the facility prior to employment on 08/20204. Moreover, LPA Brown observed Staff #3 (S3) working at the facility and per documents review, S3 does not have criminal record clearance prior to employment on 07/2024. Technical Assistance issued.

Additionally, LPA observed facility to have required single entry point with Sign In/Sign Out for Residents and Visitors upon entering the facility. LPA observed planned activities for the residents such as books and games. Menu for the residents was also noted.

The facility was evaluated in accordance with the CCR, Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Pre-Licensing is incomplete and the following issues to be resolved by December 27 at 10:00 AM:
Obtain criminal record clearance for Staff #3 (S3)
Transfer/Associate Staff #1 (S1) and Staff #2 (S2) criminal record clearance to the facility.
Conduct Medication Training on all staff.

An exit interview was conducted, and a copy of this report, LIC809, LIC9102 were reviewed and provided to Administrator/Applicant Ricardo Garcia and Administrator Johnny Mazariegos.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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