Touch of an Angel Lancaster

Type of visit: Required - 1 Year

On 9/14/2026 at approximately 10:15 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the Administrator, Stacey Thomas, and stated the reason for their visit. LPA asked for the census, Staff/Client Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 11:30 AM and the following was noted: The facility is a two-story building with five (5) bedrooms and three (3) bathrooms currently occupying four (4) residents. All residents’ bedrooms are located downstairs. The remainder of the bedrooms and bathroom are located upstairs. There are two (2) designated staff rooms located upstairs. The facility has an approved fire clearance for four (4) ambulatory, one (1) non-ambulatory, and one (1) bedridden residents. Hospice waiver approved for three (3). Common areas: The living rooms and dining rooms were observed to be neat, clean and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 75°F. A fire extinguisher was observed to be located near the kitchen and dated 06/16/2026. LPA observed required postings such as See/Say Something and Personal Rights to be located throughout the common areas. A fireplace was observed to be covered and inaccessible to residents. A working telephone was observed. Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. (continued on LIC 809-C) Bathrooms: Bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations between 110-110.8 °F. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition. Staff Room: LPA observed staff rooms to be able to stay locked and inaccessible to residents. Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods were observed. Kitchen appliances observed to be working and in proper condition. The knives/sharps were observed to be kept within a locked kitchen cabinet. Garage: The garage can be accessed from inside of the facility and observed to be kept locked. The garage was observed to be used for storage purposes. Laundry Room: The laundry appliances were observed to be located inside of the garage. The laundry appliances were observed to be in proper condition. Cleaning supplies and toxins observed locked in storage closet and inaccessible to residents. Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. A locked shed was observed. There is no body of water located at the facility. Medications: Medications were observed stored in the locked cabinet located in the kitchen. First-aid kit observed. Smoke detectors and carbon monoxide observed to be working properly and were tested. Residents/Staff Records: LPA conducted a complete file review of client records. Client records appeared to be complete. Staff records: LPA conducted a complete file review of two (2) staff records. Staff records appeared to be complete. There was no immediate health and safety hazard observed during the day of inspection. Exit interview was conducted and a copy of this report was provided to the Administrator. The Annual Report was emailed to the Administrator due to technical issues with printer.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Staff did not address a resident's change in medical condition in a timely manner. Staff are not properly trained.

On 5/27/2026 at approximately 9:20 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Stacy Thomas and stated the reason for their visit. To investigate the allegation(s), at approximately 9:30 AM, LPA requested relevant documentation such as but not limited to: Staff training, Re-appraisals and Needs/Services. By 10:00 AM, LPA conducted a physical plant tour. From 09:30 AM to 12:00 PM, LPA attempted to interview six (6) residents (R1-R6), two (2) staff members (S1-S2) and conducted record review. (continue to LIC 9099-C) Substantiated Regarding the allegation: Staff did not address a resident's change in medical condition in a timely manner. It was alleged that staff did not address R1’s change of condition in a timely manner. To investigate the allegation, LPA conducted interviews with one (1) resident and one (1) staff member. LPA’s interview with S1 revealed on 5/21/2026, R1 experienced a seizure resulting in R2 calling emergency services. S1 stated this was R1’s first seizure and they do not take any medication. When LPA questioned if they have conducted re-appraisals for R1, S1 stated, “No”. LPA’s interview with R1 revealed this was not their first seizure since residing at the facility. LPA’s interview with R2 confirmed they called emergency services for R1. LPA conducted a record review of R1’s file. LPA’s record review of R1’s file revealed it to be incomplete and not updated. LPA’s record review of R1’s file confirmed there to be no re-appraisals since R1’s Admission Agreement into the facility dated 11/04/2024. Based on interviews and record review, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff are not properly trained. It was alleged S2 was not properly trained to provide care and supervision to the residents. To investigate the allegation, LPA conducted interviews with two (2) staff members. When LPA questioned S1 if they could provide them with S2’s training, S1 could not provide the documentation requested. When LPA questioned S2 if they could provide information regarding the training they have received, S2 could not provide LPA with the information requested. LPA conducted a record review of staff files. LPA’s record review of staff files revealed them to be incomplete and not updated. LPA’s record review of staff files confirmed there to be no documentation of staff training pertaining to such topics as but not limited to: Principles of good nutrition, dementia, skill and knowledge required to provide necessary resident care and supervision, knowledge required to safely assist with prescribed medications which are self-administered, and knowledge necessary in order to recognize early signs of illness and the need for professional help. Further record review revealed S1 received a Technical Assistance violation during their annual facility inspection on 8/12/2025 where, “Licensees shall maintain in the personnel records verification of required staff training and orientation” was reviewed and documented. Based on interviews and record review, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time. (continue to LIC-9099-C) Citations issued, please refer to LIC 9099-D. No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 27, 2026 · control 31-AS-20260521135543

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jun 10, 2026

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided... This requirement was not met evidenced by: Based on interviews and record review, S1 had not completed a re-appraisal for R1 since their admission into the facility which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: The Licensee/Administrator will review the regulation and email LPA Segovia a statement of understanding by POC due date: 6/10/2026. Additionally, the Administrator will email LPA Segovia a reappraisal for R1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 10, 2026

87411 Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met evidenced by: Based on interviews and record review, documentation of staff training could not be located nor provided which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: The Licensee/Administrator will review the regulation and email LPA Segovia a statement of understanding by POC due date: 6/10/2026. Additionally LPA the Licensee/Administrator will email LPA Segovia S2’s training log.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios arrived at the facility above to conduct an unannounced annual required visit. LPA rang the door bell and was contacted by the administrator. LPA explained the reason for the visit. Administrator stated they were out in the community running errands and well meet LPA at the facility. LPA was greeted and granted access by staff #1(S1). At approximately 10:20 am., LPA initiated the physical plant tour of the facility inside and out. The following was observed. LPA observed a sign in log for visitors by the entrance and required postings on a bulletin board by the dining table. Kitchen: LPA conducted a tour of the kitchen at 10:25 a.m, and observed there to be sufficient amount of two-day perishables and seven-day non-perishables food. LPA also observed a deep freezer. Food storage and preparation areas were clear of clutter. LPA observed all knives and sharps locked and inaccessible to residents in care. The Medication cabinet was in the kitchen and was observed to be locked. LPA observed a fire extinguisher by the kitchen to be fully charged. Bedrooms: There are three (3) bedrooms for residents' use. Bedrooms may be shared. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. LPA observed extra linens in residents' closets. Bathrooms: There are two (2) bathrooms for residents. One (1) bathroom is located in a shared bedroom for private use. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. Hot water temperature was measured at 10:45 a.m., and read 116.2 degrees Fahrenheit. Common Areas: LPA observed the living areas and the dining areas to be neat and clean. At 12:14 p.m., the administrator tested the dual smoke detectors and carbon monoxide detectors and they were observed to be operational. Laundry/Garage: LPA observed a washer and dryer in the garage. The garage is attached and accessible through one of two doors. Detergent and cleaning supplies are kept locked in a cabinet in the garage. Surrounding Grounds: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with an outdoor umbrella for shade. No bodies of water observed. Entry/exits were free of obstruction. Administrative: LPA reviewed facility's, Infection Control Plan, liability insurance and Emergency Disaster Plan (LIC610E). Resident and Staff Files: At approximately 11:15 a.m., LPA conducted a file review of four (4) out four (4) resident records and three (03) staff files to insure compliance of licensing forms. Medications: Centrally Stored Medication and Medication Records were reviewed for proper documentation. LPA observed a first aid kit fully stocked on the refrigerator. No deficiencies cited. Exit interview was conducted. A copy of report provided.the state’s words, verbatim · CDSS document, Aug 12, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the administrator Stacey Thomas. The applicant is "TOUCH OF AN ANGEL LANCASTER LLC" and this is a "Change of Ownership" application. A fire clearance was approved on 07/02/24 for four (4) ambulatory residents, and room #3 approved for one (1) non-ambulatory, and (1) bedridden for a total capacity of 6. Facility has a Hospice waiver approved for three (3) residents. The facility is a two story home with the second floor designated for live-in staff only. The facility has a total of three (3) bedrooms and two (2) bathrooms for resident use. A tour of the physical plant was initiated at approximately 10:00 a.m. and the following was observed: KITCHEN: The facility has a kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of perishable and nonperishable food; properly stored. LPA observed a fire extinguisher, fully charged. BEDROOMS: There are three (3) bedrooms designated for residents' use: all three (3) bedroom are shared. The bedrooms are furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage. BATHROOMS: The facility has two (2) shared bathrooms for clients' use. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at 117°F. LAUNDRY ROOM: The laundry room is located in the garage accessible to residents. Laundry detergents and other cleaning agents were locked in a cabinet inside the garage inaccessible to residents in care. The cleaning supply cabinet was observed to be locked during visit. (continue to LIC 809-C) COMMON AREAS: These included the living area, sitting area and the dining area. Living area and sitting area are furnished with chairs, sofas and side tables. The living room area was furnished with a television, a coffee table and sofas sit the capacity of the facility. There were no visible immediate hazards. There is a working telephone line and internet accessible to residents. Smoke and carbon monoxide alarms were tested and observed to be operable. MEDICATIONS: The medication cabinet is located in the kitchen and has a locking mechanism. A complete first aid kit is located in the kitchen. Staff/Resident Records: Staff and resident records are kept in the filing cabinet. LPA and applicant discussed thee (3) of three (3) resident records. LPA shared best practices and forms required in residents' files. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a table and chairs with an umbrella to provide shade for residents. A shed that was observed locked used for storage. GARAGE: The garage stores extra facility supplies and cleaning supplies as well as detergents that were observed locked in cabinets. Component III was conducted with the applicant/administrator. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 19, 2024