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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700321
Report Date: 10/16/2024
Date Signed: 10/16/2024 11:52:00 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/16/2024 11:52 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:ANGEL CONNECTION NURSING SERVICESFACILITY NUMBER:
194700321
ADMINISTRATOR/
DIRECTOR:		MERJILYN CHUFACILITY TYPE:
300
ADDRESS:3816 STINEMAN CT. #104TELEPHONE:
(562) 420-4695
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: CENSUS: DATE:
10/16/2024
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mel Redondo - Executive Director and Laila Leah Dominguez - HR ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Home Care Services Bureau Enforcement Analyst (EA) Ryan Chan arrived at the business office of Angel Connection Nursing Services on 10/16/24 for a biennial inspection. Upon arrival, EA identified himself and was greeted by Executive Director Mel Redondo, then shortly after HR Manager Laila Dominguez arrived. The proper posting of business hours and license was observed. EA was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with Mel Redondo and Laila Dominguez. EA informed them of the deficiencies found and explained they would be noted on the 809D. Mel Redondo and Laila Dominguez were advised that home care aide (HCA) staff without proof of negative tb test are not to be with clients.

EA concluded the visit with an exit interview and provided a copy of this report along with appeal rights.

LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/16/2024 11:52 AM - It Cannot Be Edited


Created By: Ryan Chan On 10/16/2024 at 09:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: ANGEL CONNECTION NURSING SERVICES
FACILITY NUMBER: 194700321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
Section Cited
1796.45 (d)
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1796.45(d) After each examination, an affiliated home care aide shall submit, and the home care organization shall keep on file, a certificate...showing that the affiliated home care aide was examined and found free from active tuberculosis disease.
This requirement is not met as evidenced by:
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Based on records reviewed, HCO did not ensure that there was proof of tb clearance on file for home care aide staff (S5 and S7). This poses an immediate health and safety risk to clients in care.
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Type A
10/17/2024
Section Cited
1796.45 (c)
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1796.45(c) After...examination...home care aide whose test for tuberculosis infection is negative shall...undergo an examination at least once every two years. Once...positive test for tuberculosis... followed by an X-ray, the examination is no longer required.
This requirement is not met as evidenced by:
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Based on records reviewed, HCO did not ensure that home care aide staff (S4) completed tb test at least once every two years. This poses an immediate health and safety risk to clients in care.
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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.
LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/16/2024 11:52 AM - It Cannot Be Edited


Created By: Ryan Chan On 10/16/2024 at 11:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: ANGEL CONNECTION NURSING SERVICES
FACILITY NUMBER: 194700321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2024
Section Cited
1796.44(c)
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1796.44(c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training...which shall include, but not be limited to, the following...(c)(1)...(c)(2)...(c)(3)...(c)(4)...(c(5).
This requirement is not met as evidenced by:
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Based on records reviewed HCO did not ensure that home care aide staff (S1, S2, S3, S4, S5, S6, S9, and S10) completed annual training. This poses apotential health and safety risk to clients in care.
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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.
LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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