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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603083
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:03:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20221219161347
FACILITY NAME:ANGELS IN GRACEFACILITY NUMBER:
374603083
ADMINISTRATOR:CASTRO, MARIA EUGENIAFACILITY TYPE:
740
ADDRESS:349 VIA METATETELEPHONE:
(760) 724-2354
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rosio Maribel FerrerTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Licensee did not maintain fire safety requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced investigation visit to open a complaint investigation regarding the above mentioned allegation. LPA was greeted by and identified herself to Caregiver Rosio Maribel Ferrer. LPA spoke with Administrator Maria Eugenia Castro via telephone and explained the purpose of the visit and the basic elements of the complaint.

During today’s visit, LPA toured the facility, reviewed and obtained copies of facility records, and interviewed staff.

The Department's investigation consisted of observations, records review, and a tour of the facility. LPA conducted a tour of the facility accompanied by Caregiver Ferrer and Administrator via phone and observed the facility's living room, dining room, kitchen, four bedrooms being used for residents, two bathrooms, the garage, and the backyard.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20221219161347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELS IN GRACE
FACILITY NUMBER: 374603083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2022
Section Cited
CCR
87202(a)(2)
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87202 Fire Clearance (a) All facilities... Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons
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Administrator will submit a updated fire clearance request, an LIC200 and an updated facility sketch to the Department by POC due date.
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This requirements has not been met as evidenced by: Based on observation and record review, the facility does not have a fire clearance for bedridden residents. This poses an immediate safety risk to 2 of 5 residents in care. A civil penalty of $500 was assessed.
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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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20221219161347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ANGELS IN GRACE
FACILITY NUMBER: 374603083
VISIT DATE: 12/28/2022
NARRATIVE
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 LPA tested the facility's smoke detectors and found them to be operational. Two residents were observed to be residing in a room cleared for staff use. Review of resident records revealed that 2 of 5 residents are bedridden. Review of the facility's fire clearance and license revealed that the facility does not have a fire clearance for retaining bedridden residents.

The Department has investigated the above-mentioned allegation and based on observation and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. A civil penalty in the amount of $500 has been assessed during today's visit.

An exit interview was conducted with Caregiver Rosio Maribel Ferrer with Administrator Maria Eugenia Castro on the telephone, and a copy of this report, the LIC421IM (7/17), and the Licensee Appeal Rights (LIC9058 01/16) were provided to Rosio Maribel Ferrer via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3