197607962-6-19-2023-28-AS-CWOG-CSXU4A-20230619151449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607962
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:47:21 PM

Document Has Been Signed on 06/19/2023 04:47 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
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:	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: 5	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Joel Basilio		TIME COMPLETED:	03:30 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 (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with caregiver Maryanne Vergara and 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 staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies and has an Infection Control Plan. 2. Operational Requirement: The facility has a dementia care plan to accept or retain residents with dementia. There is currently one resident is on hospice and bedridden which is under the fire clearance requirement. The facility has the sufficient amount for liability insurance covering injury to residents and guests. 3. Physical Plant and Environmental Safety: The facility is a single story house and located in residential neighborhood area. The facility includes family room, dining room, kitchen, living room, five residents bedrooms, one live in staff bedroom, three bathrooms, laundry room, staff office and an isle. All the passageway and drive way and patio are free of obstruction. The facility has a pool in the backyard but they were covered by the fence and they are inaccessible to residents. Bedroom#1 - #4 has one bed, one night stand, one drawer, one chair, required beddings and sufficient lighting and closet space. Bedroom#5 has two beds, two drawers, two night stands, two chairs, required beddings and sufficient lighting and closet space. The bathrooms are clean, sanitary and in an workable condition.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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
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: 06/19/2023

NARRATIVE

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All the bathrooms also have grab bar and non-skid mat. The hot water water temperature in bathroom#1 and #2 are tested between 113.1 and 118.5 degrees F and they are within the Title 22 regulation. All the kitchen appliances are working properly. All the sharp knives and utensils are stored and locked in the kitchen drawer next to the sink. All the cleaning supplies and chemicals are stored and locked in the cabinet in the laundry room. The facility has ample supply of personal hygiene products and stored in the bathroom#1, LPA inspected the carbon monoxide detectors and smoke detectors and they are interconnected and they are operable.

4. Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff all have updated First Aid and CPR certificate except the administrator.

5. Personnel Records/Staff Training: All staff files are maintained in the facility except the administrator file. The administrator is Terry McGee but due to administrator files was not maintained in the facility and LPA did not know when the administrator certificate will be expired.

6. Resident's Record/Incident Reports: All residents files are stored and maintained in the facility in the medication cabinet. The resident files do not have a complete and current record. Resident#1 is missing Resident appraisal, admission agreement. Resident#2 is missing pre-appraisal, resident appraisal, and updated physician report. Resident#3 is missing physician report and resident appraisal. Resident#4 is missing resident appraisal and physician report. Resident#5 is missing admission agreement, physician report and resident appraisal.

7. Resident's Right and 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.

8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

9. Food Services: There are sufficient food supplies of 2-days perishable and a week of non-perishable items. The food are properly stored in the refrigerator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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
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: 06/19/2023

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10. Incidental Medical and Dental: All residents medication are centrally stored and locked in the hallway medication cabinet. LPA inspected all resident medication and they all seemed accurate and updated.

11. Disaster Preparedness: The facility does not have an updated emergency disaster plan but facility does have two alternative shelter location and the facility does not have any record of the last fire or earthquake/disaster drill.

12. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia and those on hospice.

On today's visit: 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

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2023 04:47 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record reviewed, LPA did not observe any updated Administrator Certificate in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2023
	Plan of Correction
1 2 3 4	The administrator will provide the updated Administrator Certificate to LPA by POC due date.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe any training hours for administrator as administrator file was not maintained in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2023
	Plan of Correction
1 2 3 4	The administrator will send the updated training hours (20 hours annually) 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	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2023 04:47 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.267(d)

Resident's Bill of Rights

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe any staff training for resident's right which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2023
	Plan of Correction
1 2 3 4	The administrator will send the staff trianing log about resident right by POC due date.

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 record for facility drill that conduct at least quarterly for each shift which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2023
	Plan of Correction
1 2 3 4	The administrator will ensure the facility will conduct a drill at least quarterly for each shift and send the updated drill 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	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 06/19/2023 04:47 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87506(a)

87506 Residents Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed Resident#1-#5 all missing different docuements including pre-appraisal, resident's appraisal, admission agreement , physician report which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2023
	Plan of Correction
1 2 3 4	The administrator will send all the udpated residents docuemnts 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	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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