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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601604
Report Date: 04/19/2024
Date Signed: 04/19/2024 03:42:42 PM

Document Has Been Signed on 04/19/2024 03:42 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ANGEL GENESIS GUEST HOMEFACILITY NUMBER:
374601604
ADMINISTRATOR:EMILIE C. WINLANDFACILITY TYPE:
740
ADDRESS:9166 CAMINO LAGO VISTATELEPHONE:
(619) 434-4177
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Ricky Macatula, Caregiver &
Emilie Winland, Administrator		TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with administrator Ricky Macatula, Caregiver. Emilie Winland, Administrator arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) residents. During today’s inspection, there were a total of four (4) residents in care.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: Bathroom sinks were 112.6 F in the shared bedroom and 110.8 F in the hallway bathroom.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ANGEL GENESIS GUEST HOME
FACILITY NUMBER: 374601604
VISIT DATE: 04/19/2024
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[CONTINUED FROM LIC 809]

There is a pool on the premises that is covered and gated and was locked. Per staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

Deficiencies were observed and cited during today's annual inspection.

An exit interview was conducted with Emilie Winland, Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2024 03:42 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 04/19/2024 at 11:36 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGEL GENESIS GUEST HOME
FACILITY NUMBER: 374601604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 3 staff (S1) which poses/posed a potential safety risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee shall ensure that the staff renew their first aid certification by April 26, 2024. The proof shall be emailed to the licensing office/LPA by April 26, 2024. POC is due to CCL by 04/26/2024
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 residents (R1& R2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee agreed to coordinate with R1’s physician to obtain a current LIC602 Physician’s Report for R1 and R2. Licensee agreed to E-mail a copy of R1 and R2’s LIC602 to LPA. Licensee also agreed to retrain its staff on required documents for every resident and will email the training sign-in sheet, and materials to LPA by the POC due date. POC due date is 05/03/2024
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:Denise Powell
LICENSING EVALUATOR NAME:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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