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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609079
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:15:10 PM

Document Has Been Signed on 07/12/2022 03:15 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:ANGEL HOME CARE SERVICESFACILITY NUMBER:
197609079
ADMINISTRATOR:FLORES, ROWENAFACILITY TYPE:
735
ADDRESS:128 S SERRANO AVENUETELEPHONE:
(213) 568-3108
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 6CENSUS: 3DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rowena FloresTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Administrator Rowena Flores and the purpose of today’s visit was explained.

There are currently (3) clients in the facility. The facility is licensed to serve 6 developmentally disabled clients (age 18-59) and is approved for 6 ambulatory clients.

LPA and Administrator Rowena Flores toured the entire facility inside and out. The facility is a two story home located in a residential neighborhood and consists of 6 bedrooms: 4 client bedrooms, 2 bathrooms (1 bathroom that is located upstairs is a staff restroom), living room, kitchen, dining area, backyard porch with outdoor activity area and shaded seating area for clients. Laundry room is located inside the home and there are cabinets with locks above the appliances where potentially hazardous cleaning supplies and laundry detergents are stored. All client rooms were checked. Clients beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Water temperature properly measured at 110F*. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Ample supply of perishable and nonperishable food, hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. A shaded area with chairs is provided for clients in the patio area. The facility is in good repair and Facility temperature was comfortable.

(Continued on LIC809C

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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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: ANGEL HOME CARE SERVICES
FACILITY NUMBER: 197609079
VISIT DATE: 07/12/2022
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The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Clients are able to use a designated isolation room that will be used as isolation room if a COVID-19 positive case should arise.
  • 30 day supply of medication for clients
  • Facility is screening all visitors.
  • Facility has an adequate amount of PPE and facility has enough PPE for 30 days.
  • Clients were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Hand Sanitizer: Available throughout the facility for client use.
  • The clients temperature's are checked as needed.
  • Staff temperatures are checked and logged once a day.
  • Staff and clients are tested weekly for COVID-19.
  • All Staff and clients are fully vaccinated with booster.


According to the California Code of Regulations (Title 22, Division 6, Chapter 6), LPA did not observe any deficiencies, therefore no citations were issued at this time.


Exit interview conducted, a copy of this report was provided to Administrator Rowena Flores.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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