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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800986
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:21:39 PM

Document Has Been Signed on 08/04/2022 03:21 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:
08/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Adelina Esguerra- LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Maldonado met with licensee Adelina Esguerra and explained the purpose of the visit.

During the visit, LPA Maldonado requested to review client files for Clients #1-6 (C1-C6) and staff files for Staff# 1-4 (S1-S4). LPA Maldonado observed files for C1, C2, and C5 to be missing required documents, and C6 did not have a file present at the facility during the time of the visit. LPA also observed files for S2-S3 to be empty, missing the required documents, and S4 did not have a file present at the facility, nor was S4 associated to the facility.

Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809D reports.

An exit interview was conducted with licensee Adelina Esguerra and a copy of this report and appeal rights were discussed and provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/04/2022 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 08/04/2022 at 02:28 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: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance
(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:...(2)Request a transfer of a criminal record clearance as specified in Section 80019(f)
This requirement was not met as evidenced by:
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Licensee has agreed to create access to Guardian and associate the staff accordingly and provide proof of the association to LPA by the POC due date: 08/05/22.
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Based on interviews and observations, the licensee failed to associate staff to the facility prior to working, although staff has a criminal background clearance, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type B
08/19/2022
Section Cited
CCR80070(a)

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80070 Client Records
(a)The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement was not met as evidenced by:
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Licensee will review client files and obtain correct and current documentation. Copies of all documents in files will be sent to LPA by the POC due date of: 08/19/22.
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Based on interviews and observation, the licensee failed to ensure that complete and current records were mainted in the facility for each client. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/04/2022 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 08/04/2022 at 02:41 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: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited
CCR
80066(e)

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80066 Personnel Records
(e)All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.
This requirement was not met as evidenced by:
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Licensee will review staff files and obtain correct and current documentation. Copies of all documents in files will be sent to LPA by the POC due date of: 08/19/22.
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Based on observations and interviews, the licensee failed to maintain personnel records at the facility site. Records are currently at staff's home/other work place.
This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
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