ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLC

Official classification

Type A

Official code

87705(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) Licensees that use delayed egress devices on exterior doors... shall meet the following... requirements: (4) Residents who... indicate a desire to leave the facility following redirection shall be permitted... with staff supervision. The facility did not meet this requirement as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section sited above by installing a child-proof door lever latch lock on the entryway (front) door making it inaccessible to residents in care wich poses an immediate health, safety or personal rights risks to persons in care.

Official plan of correction

Licensee shall remove the child-proof door lever latch lock from the inside of the front door within 24 hours. Licensee shall submit photographic proof of the removal of latch lock, review the stated regulation, and submit a statement of understanding of regulation reviewed to LPA via email by POC due date.

Deadline recorded: Apr 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in the perimeter fence gate was locked with padlock which poses an immediate health and safety risk to five (5) out of five (5) persons in care.

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction Staff immediately removed the padlock during LPA's visit. Licensee agrees to conduct a training on mitigating elopement behaviors and send proof sign-in sheet with training topics to the Department by 1/20/2026.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in the facility did not have documentation of quarterly drills which posed a potential health and safety risk to five (5) out of five (5) persons in care.

Official plan of correction

POC Due Date: 01/20/2026 Plan of Correction Licensee agrees to conduct a training on emergency disaster preparedness and send proof the training agenda and sign-in sheet to the Department by POC date of 1/20/2026.