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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426747
Report Date: 08/29/2022
Date Signed: 08/29/2022 11:20:36 AM

Document Has Been Signed on 08/29/2022 11:20 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:ANGELIC HANDS ASSISTED LIVINGFACILITY NUMBER:
336426747
ADMINISTRATOR:LUNA, SYNTHIA MARIEFACILITY TYPE:
740
ADDRESS:82397 STRADIVARI ROADTELEPHONE:
(760) 342-0248
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY: 6CENSUS: 3DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tinisha Sherley - CaregiverTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Tinisha Sherley and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. LPA Colvin additionally spoke with Administrator Synthia Luna via telephone, and went over the questions/areas for the Infection Control annual. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Synthia Luna, who LPA Colvin found to be successfully incorporating the several aspects of COVID-19 best practices. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, except for the master bathroom, which LPA Colvin observed to be missing paper towels. Staff were able to remedy this issue during LPA Colvin's inspection, therefore, LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note instead of a deficiency. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in a locked cabinet. LPA Colvin observed a minimal supply of masks and gloves, and no face shields or goggles. Staff were unaware of the presence of the missing item(s). TA Advisory Note issued due to best practices for the facility to have a 30-day supply on hand at all times. LPA Colvin went over the various recommended training for facility staff with Administrator Synthia Luna in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Synthia Luna informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a TA Advisory Note during today's inspection for staff not being fit tested for N95 masks.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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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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
RIVERSIDE, CA 92507
FACILITY NAME: ANGELIC HANDS ASSISTED LIVING
FACILITY NUMBER: 336426747
VISIT DATE: 08/29/2022
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 LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. Additionally, LPA Colvin observed staff Tinisha Sherley to not be wearing any type of face covering. At this time, face coverings are still required in all residential facilities. LPA Colvin will be issuing a TA Advisory Note for staff not wearing a face covering. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility.

Other: LPA Colvin observed a lock with a chain (similar to what someone might put on the side of the front door inside the home for extra security) on the door of an unoccupied, but designated resident bedroom. LPA Colvin will be issuing a TA Advisory Note as staff removed the lock during today's inspection, and the room is not currently in use. LPA Colvin warned the Administrator about using these types of locks, and that we cannot have them on any resident bedroom at any time.

An exit interview was conducted with Administrator Synthia Luna and a copy of this report and LIC9102 TA Advisory Notes was provided to staff Tinisha Sherley, who additionally signed for the report as Administrator was not present.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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