197607962-5-30-2025-28-AS-CDCN-DH77ND-20250530214833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607962
Report Date: 05/30/2025
Date Signed: 05/30/2025 09:49:56 PM

Document Has Been Signed on 05/30/2025 09:49 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
MONTEREY PARK ASC, 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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	05/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Barbara Boiston, House Manager		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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	Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted the required annual inspection. LPAs met with the House Manager, Barbara Boiston, and the purpose of the visit was explained. The fire clearance has been approved for a capacity of 6 residents, of which (4) may be non-ambulatory. The hospice waiver is approved for 1 resident. LPAs inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools. Facility is continuing to follow their Infection Control plan. The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility. The facility is a single story home with 6 bedrooms (5 for residents and 1 staff bedroom), 3 bathrooms, living room, dining room, family room, kitchen. The facility has a swimming pool in the backyard and is surrounded by a locked gate. Bathrooms have non-skid mats in the shower area and grab bars. Knives, cleaning solutions, and disinfectants are locked. The hot water temperature was measured between the required range of 105-120 degrees F. The backyard has tables and chairs for residents to use. The facility has auditory devices at the exit doors. Sufficient food supplies of 2 day perishable and at least a week of non-perishable are observed. The kitchen is kept clean and sanitary. The facility has sufficient space to accommodate indoor and outdoor activities. LPA reviewed 3 staff files and the CPR & First aid certificates are current. LPA reviewed 6 resident files and the following documents are found - admission agreements, Identification & Emergency Information, Physician's Report, Consent forms, Resident rights, Safeguards for Personal Property Valuables form. There are 3 residents receiving hospice services and one resident on oxygen. Medications are centrally stored and locked. Resident medications are being given as prescribed. The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Emergency Disaster Plan is updated and reviewed annually. A deficiency is issued on the LIC809D form. An exit interview was held and a copy of this report was given to Barbara Boiston.

Fernando Fierros	TELEPHONE: (323) 981-3981
Cynthia D Chan	TELEPHONE: (323) 981-3370
	DATE: 05/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 05/30/2025 09:49 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
MONTEREY PARK ASC, 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: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87632(a)(1)

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents... The request shall include, but not be limited to the following: (1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which 3 out of 6 residents are receiving hospice services which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2025
	Plan of Correction
1 2 3 4	The licensee shall review the hospice care regulation and submit a request to increase the number of residents on hospice. The POC is due on 6/6/25.

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.

Fernando Fierros	TELEPHONE: (323) 981-3981
Cynthia D Chan	TELEPHONE: (323) 981-3370
	DATE: 05/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025

LIC809 (FAS) - (06/04)

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