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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800986
Report Date: 05/30/2023
Date Signed: 05/30/2023 04:35:39 PM

Document Has Been Signed on 05/30/2023 04:35 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) 332-5856
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff#1, and
Staff#2, staff in charge		TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection. The facility is licensed to serve six (6) ambulatory, mentally disabled clients from ages 18-59. LPA met with staff#1 (S1) and Staff#2 (S2) joined the visit in an 1 hour later. The annual fees were current. LPA discussed the purpose of today's visit with both staff.

During the visit, CARE tool was used; a tour of the facility conducted; food supply was reviewed; staff/clients records were reviewed; staff / clients were interviewed, and medications were reviewed.

The facility is a single family home located in a residential neighborhood. LPA observed the facility to have three (3) client bedrooms, two (2) staff bedrooms, two (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 were provided at the backyard.

LPA inspected facility common areas including the kitchen, living room, and dining area. Fire extinguisher was fully charged and last services was on 2/12/23. Fire drill was conducted on 2/12/23. 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. Staff files and clients files were current.
(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME & CARE
FACILITY NUMBER: 197800986
VISIT DATE: 05/30/2023
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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 working. Hot water temperature measured at 110.3 degrees Fahrenheit. Sharp tools and knives locked and inaccessible to clients. Hazardous items were locked and inaccessible to clients.

Medications were centrally stored, locked in a cabinet. Medications were properly logged and current.
No deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed with staff#2 and a copy is provided to facility staff, whose signature on this form confirm receipt of these documents.

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

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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