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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607962
Report Date: 06/07/2022
Date Signed: 06/07/2022 06:47:47 PM

Document Has Been Signed on 06/07/2022 06:47 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:QUEEN OF THE ANGELS ASSISTED LIVING INC.FACILITY NUMBER:
197607962
ADMINISTRATOR:TERRY & MARY MCGEEFACILITY TYPE:
740
ADDRESS:420 S. MANNINGTON PLACETELEPHONE:
(626) 430-7702
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 6DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Joel Basilio TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual visit at the facility with focus on the infection control domain. LPA met with caregiver Maryanne Veigara and Joel Basilio explained the reason for the visit.

The facility is licensed to serve 6 residents over the age of 60 years old of which 2 ambulatory and 4 non-ambulatory, and a hospice waiver for one resident. There are currently one residents on hospice. Facility cares for dementia residents and has security alarm on each exit doors. There is a swimming pool in the back yard but its gated and locked.

LPA and caregiver Joel Basilio conducted a tour of the facility and observed the following:

All common areas are clean and in good repair. Kitchen was observed clean, food was reviewed and sufficient for at least 2 days of perishables and 7 days of non-perishables. All residents bedrooms were observed, all bedrooms have sufficient lighting, furniture, and bedding. All three Bathrooms in the facility were observed. The bathroom#1 and #2, the hot water faucet are not working. Water temperature was tested in the three bathrooms and tested between 78.5 and 118.6 degrees F. which is not within the required 105-120 degrees F.

LPA reviewed all 6 residents' files and all their emergency contact information are updated. LPA reviewed 3 staff files and LPA was not able to review administrator file including the administrator certificate and health screening form. LPA reviewed all 6 residents medication and all residents medication are updated and accurate.

(Please LIC 9099 for continuation)


SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 06/07/2022 06:47 PM - It Cannot Be Edited


Created By: Christine Wong On 06/07/2022 at 04:28 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER: 197607962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA observed the bathroom#2 hot water temeperature was measured at 78.5 degrees F.
POC Due Date: 06/08/2022
Plan of Correction
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The administrator will ensure the hot water temperature of not less than 105 degrees F and not more than 120 degrees F. The administrator will fix the hot water temperuatre immediately and send the 7 days hot water log to LPA by POC due date on 06/14/22
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2022 06:47 PM - It Cannot Be Edited


Created By: Christine Wong On 06/07/2022 at 04:30 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER: 197607962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87383(a)

87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA observed the bathroom#1 and #2 -hot water faucet , the right sink near the toilet are not working.
POC Due Date: 06/21/2022
Plan of Correction
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The administrator will ensure the faciltiy are in good repair at all times. The administrator will fix the hot water faucet in bathroom#1 and #2 and send the receipt to LPA by POC due date 6/21/22
Type B
Section Cited
CCR
87412(g)
87412 Personnel Records
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the administrator file was not located in the facility and LPA was not able to review administrator certificate and health screening.
POC Due Date: 06/21/2022
Plan of Correction
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The adminisrator will ensure all the personnel record shall be maintained at the facility and available for licensing to review The admistrator will email the copy of administrator certificate and health screening to LPA by POC due date
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER: 197607962
VISIT DATE: 06/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, the facility is disinfected every 2 hours, bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are stored for more than 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to Staff #1 (Lead Caregiver).
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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