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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 11:40:22 AM

Document Has Been Signed on 08/29/2022 11:40 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tinisha Sherley - CaregiverTIME COMPLETED:
11:45 AM
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During Licensing Program Analyst (LPA) Crystal Colvin's inspection at the facility for a complaint investigation (#18-AS-20220824151755), LPA Colvin was unable to access records for prior resident (R1), despite providing Administrator with a reasonable amount of time (1 hour - LPA arrived at 9:30am for Annual Inspection and informed Administrator of requested documents for Complaint at 9:54am) after LPA Colvin requested the records via telephone. Deficiency cited.

Based on LPA Colvin's observations, the facility was cited and deficiency issued. LPA Colvin conducted an exit interview with caregiver Tinisha Sherley as Administrator was not present at the facility during the inspection. A copy of this report, LIC809D and appeal rights was provided.


***LPA Colvin experienced technical diificulties during printing process, so additionall time is added. Reports emailed to Administrator while LPA Colvin present at facility.
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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Document Has Been Signed on 08/29/2022 11:40 AM - It Cannot Be Edited


Created By: Crystal Colvin On 08/29/2022 at 10:53 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: ANGELIC HANDS ASSISTED LIVING
FACILITY NUMBER: 336426747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2022
Section Cited
CCR
87506(d)

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Resident Records: (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.... This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Colvin with a complete copy of R1's file by Plan of Correction date of 8/30/22. This may be subitted via email, fax, postal mail, or drop off at the Spruce Street Office in Riverside.
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Based on observation and interview, the Licensee did not comply with the above regulation with one resident file. LPA Colvin was unable to access records for R1 during the inspection. This is an immediate safety risk to residents.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
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