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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800986
Report Date: 12/27/2021
Date Signed: 12/27/2021 01:22:54 PM

Document Has Been Signed on 12/27/2021 01:22 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:ANGELINA HOME & CAREFACILITY NUMBER:
197800986
ADMINISTRATOR:ESGUERRA, ADELINAFACILITY TYPE:
735
ADDRESS:250 W. GRAGMONT ST.TELEPHONE:
(626) 915-1974
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 4DATE:
12/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Florante Viloria, Staff
Adeline Esgerras, Licensee 		TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve six (6) mentally disabled clients from ages 18-59. Ambulatory only. Client census is four (4). LPA was allowed entry by staff, Florante Viloria. The annual fee is paid. Licensee, Adelina Esgerras, joined the visit via phone call. LPA discussed the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

The facility is a single story home located in a residential neighborhood. LPA observed the facility to have 3 client bedrooms, a Caregiver room, 2 bathrooms, living room, dining room, kitchen, garage, laundry area on the back porch and an indoor/outdoor activity area. A shaded area with chairs is provided in the rear.

LPA inspected facility common areas including the kitchen, living room, and dining area. Fire extinguisher was fully charged and the last service was on 7/10/21. Comfortable temperature of 73 degree Fahrenheit for clients was maintained. Client bedrooms were checked and closet/drawer space to accommodate each client is available. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Adequate linen and personal hygiene supply are observed. Bathrooms are operational.
(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2021
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: ANGELINA HOME & CARE
FACILITY NUMBER: 197800986
VISIT DATE: 12/27/2021
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Facility has maintained the required two (2) days perishable and seven (7) days non- perishable food. Smoke detectors and carbon monoxide detectors are operable. Hot water temperature measured at 119.2 degrees Fahrenheit. Sharp tools and knives locked and inaccessible to clients. Hazardous items were locked and inaccessible to clients. Administrator certificate current, expires on 03/26/2023.

Medications were centrally stored, locked in a cabinet. Medications were properly logged and current.

Deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed with Licensee and a copy is provided to facility staff, whose signature on this form confirm receipt of these documents.

Appeal right explained.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/27/2021 01:22 PM - It Cannot Be Edited


Created By: Bonnie Tao On 12/27/2021 at 12:48 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: ANGELINA HOME & CARE
FACILITY NUMBER: 197800986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds.
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Backyard and side areas had trash, broken furniture and debris/ hazard.
The window screen in Caregiver's room is ripped. This poses a potential health and safety risk to residents.
POC Due Date: 01/11/2022
Plan of Correction
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Administrator will ensure window screen in caregiver's room is replaced. Trash, hazard in backyard and side areas are removed. Plan of Corrections (POC) must be corrected by POC date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2021


LIC809 (FAS) - (06/04)
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