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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800986
Report Date: 03/01/2024
Date Signed: 03/01/2024 04:51:46 PM

Document Has Been Signed on 03/01/2024 04:51 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: 4DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff #1, caregiverTIME COMPLETED:
05:00 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 spoke with Staff#2 (S2) over the phone to discuss 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. Common areas were observed for the ability to safely serve the needs of the clients. All client rooms were furnished with appropriate furniture for clients’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Hot water temperature was 110.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Facility maintained a comfortable temperature for clients. A sufficient supply of perishable and non-perishable foods was observed. The back yard activity area was a shaded area with chairs. Smoke and carbon monoxide detectors were tested and operational. The last Fire/ Emergency Drill was conducted on 12/12/23. The fire extinguishers were fully charged. Medications were centrally stored, locked and the records were current. Hazardous items and sharp items were locked and inaccessible to clients.

No deficiencies were cited per California Code of Regulations, Title 22. An Exit conference was conducted and LIC 809 report was provided to Staff#1.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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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