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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700708
Report Date: 09/04/2024
Date Signed: 09/04/2024 04:00:30 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/04/2024 04:00 PM - 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:ARCHANGEL CARE SERVICES LLCFACILITY NUMBER:
194700708
ADMINISTRATOR/
DIRECTOR:		REGALIZA, MARILENEFACILITY TYPE:
300
ADDRESS:5750 DOWNEY AVENUE, STE 301TELEPHONE:
(562) 252-2310
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: CENSUS: DATE:
09/04/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Maria Nonato - Officer In ChargeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Home Care Services Bureau Enforcement Analyst (EA) Ryan Chan arrived at the business office of ARCHANGEL CARE SERVICES LLC on 9/4/24 for a biennial inspection. Upon arrival, EA identified himself and was greeted by Maria Nonato (Officer In Charge). The proper posting of business hours and license was observed. The analyst 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 Maria Nonato. The analyst informed Maria Nonato of the deficiencies found and explained they would be noted on the 809D. Maria was advised that home care aide staff may not be with clients without proof of negative TB testing.

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

LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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 09/04/2024 04:00 PM - It Cannot Be Edited


Created By: Ryan Chan On 09/04/2024 at 03:02 PM
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: ARCHANGEL CARE SERVICES LLC
FACILITY NUMBER: 194700708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2024
Section Cited
1796.45(a)
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1796.45 (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.
This requirement is not met as evidenced by:
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Based on records reviewed licensee did not ensure home care aides (S3 and S12) competed their TB testing prior to being placed with clients which poses an immediate risk to the health and safety of 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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 09/04/2024 04:00 PM - It Cannot Be Edited


Created By: Ryan Chan On 09/04/2024 at 03:24 PM
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: ARCHANGEL CARE SERVICES LLC
FACILITY NUMBER: 194700708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
1796.44(c)
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1796.44(c)...an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific, which shall include...
This requirement is not met as evidenced by:
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Based on records reviewed licensee did not ensure home care aides (S3, S8, S9, S12) completed annual training which poses a potential risk to the health and safety of 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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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