197607882-7-15-2023-11-AS-EDAT-CTRPUJ-20230715113736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607882
Report Date: 07/15/2023
Date Signed: 07/15/2023 11:38:04 AM

Document Has Been Signed on 07/15/2023 11:38 AM - 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, 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: 3	DATE:	07/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Gina Balderas & Elvira Brondial		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/15/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with lead caregivers Elvira Brondial and Gina Balderas. LPA explained the purpose of today’s visit. Raquel Monzones the administrator was unavailable to be present for the visit. The facility is licensed to operate for (6) bedridden elderly adults ages 60 and above. Currently, the facility has (1) hospice resident in care. 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. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.8 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order and complete. (Evaluation Report continues LIC 809-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ANGEL ASSISTED LIVING SERVICES	FACILITY NUMBER: 197607882
	VISIT DATE: 07/15/2023

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 07/02/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 12/09/22 – 12/09/23. The facility is current with annual license fees.

An audit of resident #1-#3 (R1-R3) service files and staff #1-#5 (S1-S5) personnel files revealed to be complete. Interviews were conducted with (3) residents and (3) staff. The facility has the current administrator's certification on file for Raquel Monzones #6044011740 - Expiration: 07/19/2023.

No deficiencies during this inspection visit.

An exit interview was conducted with Elvira Brondail and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023

LIC809 (FAS) - (06/04)

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