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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426747
Report Date: 10/13/2022
Date Signed: 10/13/2022 01:27:14 PM

Document Has Been Signed on 10/13/2022 01:27 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
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: 1DATE:
10/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tinisha Sherley - CaregiverTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin was at the facility conducting an investigation on open complaints (#18-AS-20220824151755 & #18-AS-20221006144016) when LPA Colvin observed the following items which were addressed:
  • Admissions Agreements/Other Fees: In reviewed of resident's (R1) Admissions Agreement, LPA Colvin observed that R1's Admissions Agreement had additional Optional Services hand written in, such as "haircuts, pedicures & manicures, transportation, private caregiver". LPA Colvin that there was no list of fees for each item, and only the basic service fee of $7,500 was listed. Deficiency cited. LPA Colvin additionally observed that the Admissions Agreement the facility used for R1 is significantly different than that which was approved by Licensing from the facility's application for a License. Deficiency cited.

  • Pre-Admissions Fee Refunds: LPA Colvin observed that Resident 2 (R2) resided in the facility for less than three weeks and their family was not provided with any refund of the $1,500 Pre-Admission Fee. LPA Colvin notes that Title 22 Regulations has a very specific refund schedule for Pre-Admission Fees in excess of over $500. R2 should have been refunded $800 of the fee (80% of the amount over $500, or 80% of $1,000) due to passing away within the first 30-days of tenancy. Deficiency cited.

  • Reporting Requirements: LPA Colvin observed that R2's tenancy at the facility ended due to R2's passing away at the end of the month in September. Licensing does not have any record on file of the facility reporting R2's passing, as they are required to do for each resident within seven (7) days of their passing. Deficiency cited.

  • Resident Records: LPA Colvin did not have access to resident files during today's inspection, and Administrator was unable to provide access, as they had an appointment in another city.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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: 10/13/2022
NARRATIVE
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Deficiency cited. Since this is a repeated deficiency, LPA Colvin wil be assessing a $250 civil penalty on today's date.

Based on observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC809D. A copy of this report, LIC809Ds, LIC421FC, and appeal rights were provided to caregiver Tinisha Sherley, who refused to sign the report.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2022 01:27 PM - It Cannot Be Edited


Created By: Crystal Colvin On 10/12/2022 at 10:03 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: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited
CCR
87507(g)(5)(E)(2)(b)

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Admission Agreements: (g)...shall..:(5) Refund...(E) Preadmission fees shall be refunded...: 2...fees that are greater than ...($500) shall be refunded...:a. A refund of at least 80 percent...iin excess of $500...resident leaves the facility for any reason during the first month of residency.
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Licensee agrees to provide a refund of $800 to R2's family, as well as review Title 22 Regulations section 87507 in regards to Admissions Agreements, Licensee to provide LPA Colvin with proof of refund to R2's family and may self-certify that they have thuroughly read the regulation section. Due by 10/14/22
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The Licensee did not comply with the above regulation with at least one resident. R2resided at the facility for less than one month before passing away. Family removed items from facility and was not provided any refund of preadmission fees. This was an immediate personal rights violation of R2.
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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: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2022 01:27 PM - It Cannot Be Edited


Created By: Crystal Colvin On 10/12/2022 at 10:31 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: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
87507(g)(3)(B)(1)

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Admission Agreements: (g)...shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including: 1. A...description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services...
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Licensee agrees to provide LPA Colvin and R1 with a detailed breakdown of costs for each additional fee charged to R1, per what is listed in the Admissions Agreement, as well as how frequently these services are/where provided and charged. Due by Plan of Correction date of 10/28/22.
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The Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R1's agreement had written in additional services (hairbuts, transportation), without listing cost of these additional services. This was a potential personal rights violation of R1.
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Type B
10/28/2022
Section Cited
CCR87208(a)(2)

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Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes in the plan of operation...shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (2)...Admission Agreement...
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Licensee agrees to immediately cease using the Admissions Agreement used for R1, as LPA Colvin observed multiple Title 22 violations in the document. Licensee to either return to initial approved agreement, or create a new Admissions Agreement and submit to LPA Colvin for review prior to use. Licensee to
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The Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that the Admissions Agreement for R1 was entirely different than the Admissions Agreement Licensing has on file from the application for licensure. This is a potential personal rights violation of R1.
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additionally review all current resident files and deermine if any residents have a signed Admissions Agreement other than what was previously approved during facility's application for a license. Licensee to inform LPA Colvin of findings of audit. Due by Plan of Correction date of 10/28/22.
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: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2022 01:27 PM - It Cannot Be Edited


Created By: Crystal Colvin On 10/12/2022 at 10:43 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: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
87211(a)(1)(A)

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events...(A)Death of any resident from any cause regardless of where the death occurred...
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Licensee agrees to provide LPA Colvin with a Death Report for R2. Due by Plan of Correction date of 10/28/22
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The Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R2 passed away in September 2022, but Licensing never received a Death Report from the facility.
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Type B
10/28/2022
Section Cited
CCR87506(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 R2's file by Plan of Correction date of 10/28/22. 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 R2 during the inspection. This is a potential personal rights violation.
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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: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


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