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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800986
Report Date: 08/26/2022
Date Signed: 08/26/2022 02:45:58 PM

Document Has Been Signed on 08/26/2022 02:45 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:
08/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lenimar Sabate- StaffTIME COMPLETED:
02:50 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 staff Lenimar Sabate 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). During the review of C2's file, it was observed that the licensee is C2's representative payee and the licensee has failed to maintain accurate records of client's safeguarded cash resources.

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

An exit interview was conducted with staff Lenimar Sabate 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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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 2
Document Has Been Signed on 08/26/2022 02:45 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 08/26/2022 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: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
CCR
80026(h)(1)

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80026 Safeguards for Cash Resources...
(h)Each licensee shall maintain accurate records of accounts of cash resources... entrusted to his/her care, including, but not limited to the following:(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
This requirement was not met as evidenced by:
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The licensee will fax LPA proof of bank statements/ledgers/receipts for every deposit and/or withdrawl of cash resources for the client by the POC due date of 09/02/2022. The licensee will also include and maintain these records in the client's file.
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Based on file review, observations, and interviews, the licensee failed to maintain accurate records of clients' cash resources maintained or receipts of cash provided to clients from their account. 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: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022


LIC809 (FAS) - (06/04)
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