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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802313
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:11:54 PM

Document Has Been Signed on 08/18/2022 04:11 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:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 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). Facility annual fees were current. LPA met with caregiver, Lucita Atanacio, who assisted with visit. Administrator certificate is current and expires on 3/26/2023. LPA discussed with staff 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. The facility consisted of three (3) clients’ bedroom, caregiver’s room, two (2) bathrooms, a kitchen, dining room, a family room with a TV, laundry area in the back porch and an indoor/outdoor activity area. A shaded area with chairs was provided in the rear. Bathrooms are clean and operable. 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 were observed. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility. Smoke detectors and carbon monoxide detectors are operable. Hot water temperature was measured at 107.5 degrees Fahrenheit. Medications are centrally stored and locked. Medications were properly logged and current. Hazardous items were locked and inaccessible to clients. Fire extinguisher was fully charged. Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. 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: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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