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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197607962
Report Date:
05/23/2024
Date Signed:
05/23/2024 03:52:14 PM
Document Has Been Signed on
05/23/2024 03:52 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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER:
197607962
ADMINISTRATOR/
DIRECTOR:
TERRY & MARY MCGEE
FACILITY TYPE:
740
ADDRESS:
420 S. MANNINGTON PLACE
TELEPHONE:
(626) 430-7702
CITY:
WEST COVINA
STATE:
CA
ZIP CODE:
91791
CAPACITY:
6
CENSUS:
6
DATE:
05/23/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:
Joel Basillo
TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with caregiver Joel Basilio assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is licensed to serve elderly residents age 60 and above. The fire clearance approved for two (2) ambulatory and four (4) non-ambulatory residents age 60 and above. Approved to accept or retain resident one (1) on hospice.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
1. Infection Control: The facility does not have an infection control plan in place but they continue to practice hand washing and disinfect in the facility. Facility has sufficient PPE supplies. All staff does not have any health screening and TB test result in their personnel file.
2. Operational Requirement: he facility has a dementia care plan to accept or retain residents with dementia. Currently there's one resident is on hospice and no resident is bedridden which is under the fire clearance requirement. The liability insurance was not able to review during the annual inspection.
3. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area, the facility includes: living room, family room, dining room, kitchen, live in staff room, five residents bedrooms, three bathrooms and a detached garage. Bedroom#1 has two beds, two drawers, required beddings and furniture and sufficient lighting and closet space. Bedroom#2 to #5 has one bed, one chair, one drawer, required beddings and sufficient lighting and closet space. All the bathrooms have the required grab bar and non-skid mat. The hot water temperature tested in Bathroom#2 and bathroom were 116.4 and 118.4 which are within the Tittle 22 regulation. The hot water in Bathroom#1 is not operating. All the chemicals are stored and locked under the kitchen sink. All the appliances in the kitchen are working properly. The facility has a telephone on the premises.
SUPERVISORS NAME
:
David Sicairos
LICENSING EVALUATOR NAME
:
Christine Wong
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
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
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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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER:
197607962
VISIT DATE:
05/23/2024
NARRATIVE
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4. Staffing: Facility has sufficient staffing to provide care and supervision to residents. The facility has at least one person to have CPR and First Aid Training on duty. All the staff are over 18 years old.
5. Personnel Record-Training: All staff files are locked in a locked box under the staff desk. All the staff are fingerprint cleared and associated with the facility. The administrator file was not in the facility and LPA was not able to review administrator qualification.
6. Resident's Right-Information: The facility has all the posted include resident's personal right and complaint poster..etc and its located on the wall near the entrance. The facility also has internet service device for residents to use.
7. Planned Activity: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
8. Food Service: The facility has two days perishable and seven days non perishable food supply. All the food are stored properly in the facility. No resident in the facility required any modified diet that prescribed by the doctor.
9. Internal Medical and Dental: The resident family usually arrange resident's medical and dental appointments. All the resident's medication are centrally stored and LPA inspected all six residents medication and they all seemed accurate and up-to-dated. All the residents have the 30 days supply of medication.
10. Resident Record-Incident Report: All the client's files are stored at the Medication Cabinet near the entry way. LPA inspected all six residents files. All resident files have the face sheet, pre-appraisal and resident's appraisal in file but LPA observed R1, R2, R3 and R4 do not have the updated needs and service plan/appraisal. R2 does not have the updated physician report and the last one was dated back in 2018, R3 does not have any physician report prior the admission. R3 also does not have the signed admission agreement in file.
11. Disaster Preparedness: The facility does not have an updated Emergency Disaster Plan and last one was updated back in 2010. The facility does not have any documentation for fire/disaster drill. The facility does have two alternative shelter location.
SUPERVISORS NAME
:
David Sicairos
LICENSING EVALUATOR NAME
:
Christine Wong
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
8
of
9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER:
197607962
VISIT DATE:
05/23/2024
NARRATIVE
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12. Residents with Special Health Needs: Currently the facility has two residents are on home health and one resident is on hospice. All the home health information and hospice record are along in resident's files. The facility has a swimming pool in the backyard and it's fenced and compliance with the state and local building codes. All the sharp knives and utensils are stored and locked in the kitchen drawers. The dementia resident does not have an updated Needs and Service plan in file.
Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8
Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the caregiver Joel Basilio
SUPERVISORS NAME
:
David Sicairos
LICENSING EVALUATOR NAME
:
Christine Wong
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
7
of
9
Document Has Been Signed on
05/23/2024 03:52 PM
- It Cannot Be Edited
Created By:
Christine Wong
On
05/23/2024
at
03:26 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:
05/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA did not observe S1 and S2 has the health screening and chest x ray result in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
Administrator will send the copy of health screening for S1 and S2 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:
David Sicairos
LICENSING EVALUATOR NAME:
Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
05/23/2024 03:52 PM
- It Cannot Be Edited
Created By:
Christine Wong
On
05/23/2024
at
03:26 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:
05/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(12)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the facility does not have any infection control plan in place which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will submit the infection control plan to LPA by POC due date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA was not able to review the updated liability insurance policy during the inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will send the updated liability insurnace policy 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:
David Sicairos
LICENSING EVALUATOR NAME:
Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
05/23/2024 03:52 PM
- It Cannot Be Edited
Created By:
Christine Wong
On
05/23/2024
at
03:26 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:
05/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(a)(1)
Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. (1) Applicants who possess a valid Nursing Home Administrator license, issued by the California Department of Public Health, shall be exempt from completing an approved Initial Certification Training Program and taking a written exam, provided the individual completes twelve (12) hours of classroom instruction in the following Core of Knowledge areas:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on which record review, LPA was not able to review the administrator file in the facility during the inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will send all the documents for the administrator to LPA by POC due date.
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA did not observe R3 has any physician report in resident's file since admitted to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will send the copy of R3's physician report 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:
David Sicairos
LICENSING EVALUATOR NAME:
Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
05/23/2024 03:52 PM
- It Cannot Be Edited
Created By:
Christine Wong
On
05/23/2024
at
03:26 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:
05/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA observe R2 did not have an updated physician report and last one was conducted in 2018 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will send the updated physician report for R2 to LPA by POC due date.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA observe R1 to R4 do not have any updated Needs and service plan in residents' files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will send R1-R4 needs and service plan 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:
David Sicairos
LICENSING EVALUATOR NAME:
Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
05/23/2024 03:52 PM
- It Cannot Be Edited
Created By:
Christine Wong
On
05/23/2024
at
03:26 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:
05/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, , LPA did not observe any fire drill documentation/log book in faciltiy which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will send the fire/disaster drill log to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the facility does not have an updated Emergency Disaster Plan in place, the last one was updated back in 2010 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will send the updated LIC610D Emergency Disaster Plan 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:
David Sicairos
LICENSING EVALUATOR NAME:
Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
05/23/2024 03:52 PM
- It Cannot Be Edited
Created By:
Christine Wong
On
05/23/2024
at
03:43 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:
05/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed the bathroom in Bedroom#1 and the hot water was not working which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/06/2024
Plan of Correction
1
2
3
4
The administrator will fix the hot water in the bathroom in Bedroom#1 and send the plumber receipt to LPA by POC due date.
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:
David Sicairos
LICENSING EVALUATOR NAME:
Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE:
05/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2024
LIC809
(FAS) - (06/04)
Page:
9
of
9