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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410309
Report Date: 10/09/2023
Date Signed: 10/09/2023 04:13:38 PM

Document Has Been Signed on 10/09/2023 04:13 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANJEGO HOME CAREFACILITY NUMBER:
366410309
ADMINISTRATOR:GARCIA, LANI B.FACILITY TYPE:
740
ADDRESS:25531 VAN LEUVEN STTELEPHONE:
(909) 799-1032
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY: 6CENSUS: 5DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lani Garcia, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Lani Garcia, Administrator, and discussed the purpose of the visit.
The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (5) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:
LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility backyard is enclosed by a fence with self-latching gates and shaded area is sufficient for resident activities.
LPA inspected the kitchen. The refrigerator and freezer are operating in a healthful manner. Hot water temperature is maintained at 106 degrees F. Facility has sufficient non-perishable and perishable food supply for residents in care. Facility has sufficient cups, plates, and utensils for residents use.
LPA inspected resident bedrooms. Bedrooms are equipped with beds, bed linen, nightstands, chairs, storage space, and sufficient lighting.
LPA inspected resident bathrooms. Bathroom equipment is fully operational. Hot water temperature in bathroom #1 tested at 106 degrees F. Hot water temperature in bathroom #2 tested at 127 degrees F with no warning signs displayed.
LPA observed operating carbon monoxide alarms and telephone service.
LPA observed posted in a common area Community Care Licensing and Ombudsman posters. Emergency exiting plans and telephone numbers were not posted at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANJEGO HOME CARE
FACILITY NUMBER: 366410309
VISIT DATE: 10/09/2023
NARRATIVE
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 LPA observed facility has a complete first aid kit. Facility has sufficient linen, emergency supplies, and personal hygiene products for residents. Sharps, disinfectants, cleaning solutions, and toxins are kept in a locked cabinet.
Resident medications are kept in a safe and locked cabinet, inaccessible to residents in care. All medications are labeled and administered as prescribed.
LPA reviewed staff files for first aid certifications, fingerprint clearances, health screenings, training, and personnel records. Staff #1 (S1) and staff #2 (S2) had incomplete health screenings. S1 and S2 job training verifications were not maintained in staff personnel files.
LPA reviewed residents files for admissions agreements, physician's reports, assessments, and personal rights. All the required documentation.

Deficiencies were cited during today's visit.

An exit interview was conducted, where licensing reports and plan of corrections were discussed. Copies of the reports with appeal rights were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 10/09/2023 04:13 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/09/2023 at 02:52 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: ANJEGO HOME CARE
FACILITY NUMBER: 366410309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by hot water temperature in bathroom #2 tested at 127 degrees F and was not identified with warning signs, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2023
Plan of Correction
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Licensee/Administrator shall submit to the licensing agency proof of correction by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/09/2023 04:13 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/09/2023 at 02:52 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: ANJEGO HOME CARE
FACILITY NUMBER: 366410309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above by staff #1 and staff #2 having incomplete health screenings which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee/Administrator shall submit to the Licensing agency proof of complete health screening for staff #1 and #2 by POC date

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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 10/09/2023 04:13 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/09/2023 at 02:52 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: ANJEGO HOME CARE
FACILITY NUMBER: 366410309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above by Licensee did not maintain liability insurance for the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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Licensee/Administrator shall submit to the Licensing agency proof of insurance by POC date
Section Cited
Personnel Records
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/09/2023 04:13 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/09/2023 at 02:52 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: ANJEGO HOME CARE
FACILITY NUMBER: 366410309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on LPA file review, the licensee did not comply with the section cited above by staff #1 and Staff #2 did not have verification of job training in their personnel files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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2
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Licensee/Administrator shall submit to the Licensing agency proof of staff training by POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 10/09/2023 04:13 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/09/2023 at 03:36 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: ANJEGO HOME CARE
FACILITY NUMBER: 366410309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(c)
Emergency Disaster Plan 87212 (c): Emergency exiting plans and telephone numbers shall be posted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by emergency exiting plans and telephone numbers were not posted at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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4
Licensee/Administrator shall provide to the Licensing agency proof of emergency plans and numbers posted at the facility by POC date
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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