197607882-7-13-2024-11-AS-RCLD-D75R5X-20240713124352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607882
Report Date: 07/13/2024
Date Signed: 07/13/2024 12:44:03 PM

Document Has Been Signed on 07/13/2024 12:44 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ANGEL ASSISTED LIVING SERVICES		FACILITY NUMBER:	197607882
ADMINISTRATOR:	ELVIRA CLAVERIA		FACILITY TYPE:	740
ADDRESS:	4401 234TH PLACE		TELEPHONE:	(310) 373-9275
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 6	DATE:	07/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Licensee Lia Joaquin		TIME COMPLETED:	01:00 PM

NARRATIVE

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On 07/13/24 at 8:45 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with lead caregiver Elvira Brondial. The Licensee Leia Joaquin joined shortly after.

The facility is licensed to operate for (6) bedridden elderly adults ages 60 and above. The facility is approved for (1) hospice resident.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (2) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, an outside seating area, and a garage.

The Caregiver accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Continue to LIC809-C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2024 12:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL ASSISTED LIVING SERVICES	FACILITY NUMBER: 197607882
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in for one out of five staff members which poses a potential safety risk to persons in care. LPA Clody did not observe Staff #1 to be associated with the facility in Guardian.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	The Licensee will associate Staff #1 to the facility and ensure that all staff are either associated via Guardian or the proper paperwork will be sent to Licensing with a follow up call to confirm associations.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL ASSISTED LIVING SERVICES	FACILITY NUMBER: 197607882
	VISIT DATE: 07/13/2024

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Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 116.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced March 27, 2024 was observed in the kitchen area. Caregiver tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates.

5 resident records were reviewed and, 5 out of 5 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. LPA Cloyd did not observe Staff #1 associated to the facility in Guardian. The issue was discussed with the Licensee.

An exit interview was conducted, technical assistance provided, Plans of Corrections were developed and reviewed and a copy of this report and appeal rights were discussed and left with the Licensee Leia Joaquin.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024

LIC809 (FAS) - (06/04)

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