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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802313
Report Date: 07/26/2021
Date Signed: 07/26/2021 05:42:33 PM

Document Has Been Signed on 07/26/2021 05:42 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 AND CARE IIFACILITY NUMBER:
197802313
ADMINISTRATOR:ESGUERRA, ADELINAFACILITY TYPE:
735
ADDRESS:622 N. WATERBURY AVENUETELEPHONE:
(626) 257-3245
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 4DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lucita Atancio, Staff in chargeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve six (6) Mentally Disable Ambulatory only clients, from age 18-59. Client census is four (4). The annual fee is paid. LPA met with caregiver, Lucita Atanacio, who assisted with visit. LPA discussed with administrator over the phone regarding the purpose of today's visit and the inspection.

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.

LPA toured the facility inside and outside. Facility is a single-story home located in a residential neighborhood consisting of three (3) clients’ bedroom, caregiver’s room, two (2) bathrooms, a kitchen, dining room, a family room with a TV, laundry area on the back porch and an indoor/outdoor activity area. A shaded area with chairs was provided in the rear. Bathrooms are operational. Facility maintains the required two (2) days perishable food and seven (7) days non- perishable food. Clients’ bedrooms have two twin beds, dresser and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. Carbon monoxide detectors are operable. Hot water temperature measured at 108.1 degrees Fahrenheit. Medications are centrally stored and locked. Medications were properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher was fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. See LIC 809 D for details.

An exit interview was conducted. This report is discussed and provided to caregiver, Lucita Atancio, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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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Document Has Been Signed on 07/26/2021 05:42 PM - It Cannot Be Edited


Created By: Bonnie Tao On 07/26/2021 at 04:40 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 AND CARE II
FACILITY NUMBER: 197802313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2021

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

This requirement is not met as evidenced by:
All client rooms were unorganized where clothes and trash all over the rooms and beds. Window at the left side of fireplace in living room and Client Room #1 had no window screen. Two stove top burners on the right side of the stove are not working.
Live cockroaches are crawling inside the food cabinet and under dining table. Backyard, front porch and side areas had trash, broken furniture and debris/ hazard. Wooden step of the side deck is broken and not stable to step on. It is a trip hazard.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Administrator will ensure all rooms are thoroughly cleaned and organized. Window screens are put in place. All stove tops are working. Pest control is serviced to infest cockroaches and pest. Trash and hazard in backyard, front porch and side areas are removed and facility is cleaned. Wooden step of the side deck is fixed and stable to step on. Plan of Corrections (POC) must be corrected by POC date of 08/05/2021.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment and Supplies
Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary;

This requirement is not met as evidenced by:

Beds in Client room #1 had no bed linens, mattress pads, fitted nor top sheet.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Licensee/ Administrator will ensure all client beds have mattress pads, fitted/top sheets and facility maintains a adequate supply of linens for all clients. The POC must be corrected by POC date of 08/05/2021.
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: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2021


LIC809 (FAS) - (06/04)
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