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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604691
Report Date: 01/29/2022
Date Signed: 01/29/2022 03:02:42 PM

Document Has Been Signed on 01/29/2022 03:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANGIE'S HOME CARE, INC.FACILITY NUMBER:
197604691
ADMINISTRATOR:HEATH, ANGELAFACILITY TYPE:
740
ADDRESS:16456 LOS ALIMOS STTELEPHONE:
(818) 366-7906
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
01/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Angie Heath - AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted an unannounced case management visit to this facility to issue a deficiency in connection with complaint control no.: 31-AS-20200911123028 wherein the facility retained Resident #1 (R1) on 07/16/20 to 08/14/20 with stage 3 pressure sore injury without hospice or home health services.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/29/2022 03:02 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 01/29/2022 at 11:10 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGIE'S HOME CARE, INC.
FACILITY NUMBER: 197604691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2022
Section Cited
CCR
87615(a)(1)

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Prohibited Health Condition (a) Persons who require health services for or have a health condition including, but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.

This requirement is not met as evidenced by:
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Administrator agreed to review regulations related to prohibited and restricted health conditions and send a written statement of understanding to CCL. Administrator and staff will complete a training on pressure injuries and proof of training will be sent to CCL on or before the POC date
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Based on LPA's record review, the licensee did not ensure that R1 was not retained with a Stage 3 or 4 pressure injury and received proper treatment of the pressure injury. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2022


LIC809 (FAS) - (06/04)
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