Angelic Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Staff Michelle Velazquez. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, of whom two (2) may be bedridden. Hospice waiver for four (4). During today’s inspection there were five (5) residents in care. LPA with Staff Velazquez toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. LPA observed Bedroom #1 as a shared resident bedroom with a bathroom. LPA observed no door between the toilet and shower area and the shared bedroom to maintain individual privacy. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Staff Velazquez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC809-C] LPA reviewed facility records. Confidential records were stored in locked areas. Interviews revealed that Staff #1 (S1) began employment with the facility more than five (5) days ago and LPA observed S1 present during today’s visit. Review of CCLD’s Guardian and Licensing Information System (LIS) databases showed that S1 had not completed the required criminal background clearance process prior to working. Two deficiencies were cited per California Code of Regulation, Title 22 (refer to the attached LIC 809-D pages). Since one of the deficiencies was related to an employee working at the facility without a background clearance, a Civil Penalty of $500 was also assessed (see the LIC421-BG page). A plan of correction was jointly formulated, and an exit interview was conducted with Staff Velazquez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Required - 1 Year

On 11/18/2024 at 12:12 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a Staff #2 (S2) and was granted entry to the facility. At the time of the visit there was one (1) staff present, and five (5) residents present. Licensee/Administrator Michelle Matamoros was contacted and informed of the visit. Licensee/Administrator Matamoros arrived during the visit. LPA Brown explained the purpose of the visit to LIcensee/Administrator Matamoros. The facility is a five (5) bedroom, two (2) bathroom home with a kitchen, dining area, living room, and an attached garage. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and two (2) resident may be bedridden. The facility's approved for four (4) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Licensee/Administrator Matamoros and S2 to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the residents/staffs shared bathroom to be at 113.9 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, labor laws and the disaster plan were posted in a common area. Cleaning supplies, toxins were kept inaccessible to residents in care. There was a designated storage space for resident/staff files.***Continuation in LIC809C*** Medications are kept inside the medication cabinet in the hallway inaccessible to residents. Overall, the facility is clean, in good repair for residents in care. During the tour of the facility, LPA Brown observed Resident #3 (R3) has a full bed rail but per documents review and staff interview, R3 is not on hospice and there's no letter submitted to CCLD and approved by CCLD for the full bed rail. Deficiency will be issued. Moreover, LPA Brown observed two (2) sharp metal skewers in the kitchen drawer, not locked and accessible to residents in care. Deficiency will be issued. Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision: LPA Brown observed that there's no staff scheduled to work the night shift, as required for facility with dementia residents. Deficiency will be issued. Record Review: LPA Brown did not observe Infection Control Plan maintained at the facility. Deficiency will be issued. LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals, needs and services plans, centrally stored medication list. LPA Brown observed Resident #2 (R2), Resident #3 (R3) do not have the required Pre-Admission Appraisal in their facility file. Deficiency will be issued. Also, LPA Brown observed no Appraisal Needs and Services Plan for Resident #2 (R2) and Resident #3 (R3). Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed Staff #2 (S2) does not have the required Health Screening/Medical Assessment in S2 personnel file. Deficiency will be issued. LPA Brown observed Staff #2 (S2), Staff #3 (S3) do not have the required 20 hours training annually. Deficiency will be issued. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) do not have the required 10 hours of initial training maintained in their facility file. Deficiency will be issued. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee/Administrator Michelle Matamoros.the state’s words, verbatim · CDSS document, Nov 18, 2024

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Michelle Matamoros and was granted entry to the facility. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, two (2) residents may be bedridden. The current census is six (6) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 120 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident and staff files. Medications are kept inside the hallway cabinet inaccessible to residents. Non-perishable and perishable food supply is sufficient for the residents in care. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA reviewed six (6) residents files for admission agreements, updated physician reports, and needs and services plans. LPA found that Resident’s R1, R2, and R3 have a condition that requires an annual updated physician report. R1’s physician report is dated 4/28/2022. R2’s physician report is dated 8/29/2019. R3’s physician report is dated 10/29/2020. The facility will be issued a deficiency for not having updated physician reports for the residents. LPA reviewed six (6) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. LPA found that Staff S1 does not have a staff file at the facility. The facility will be issued a deficiency for not having a staff file for S1. Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, and LIC811 were discussed and provided to Administrator Michelle Matamoros, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Dec 27, 2023