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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802313
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:51:09 PM

Document Has Been Signed on 07/31/2023 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
GREATER LA AC/SC, 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: 5DATE:
07/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff #1 TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/31/2023 at 8:34 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. The facility is licensed serve developmentally disabled clients 18-59 years old. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 8:47 am and was led by S1. The facility is a single-story building located in a residential area with three (3) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, living room, front yard, and backyard.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in pantry closet, to be inaccessible to five (5) out of five (5) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to five (5) out of five (5) clients in care. LPA Ramirez observed several dead and live insects in bottom sink cabinet, and pantry closet. Insects were seen crawling a bag of bread on kitchen counter and insects were seen crawling on a box of potatoes that were on the floor on nearby open back porch. LPA Ramirez observed a plastic bag containing brownish wilted green leaf lettuce sitting on the kitchen counter next to a bag of open white bread. LPA Ramirez observed other fruits and vegetables being stored in bags and boxes on the floor on open porch. Inside of microwave was observed to contain caked brownish-yellowish spatters and unknown particles stuck in and around walls of microwave. Microwave plate contained brownish and yellow stains. Outside of refrigerator contained a lock, 2- two (2) inch thick brown strips of packing tape and 2- two (2) inch thick gray strips of duck-tape that led from refrigerator door to side of refrigerator. LPA Ramirez opened refrigerator door to inspect food supply, and an insect was seen to have crawled out from under refrigerator door and ran under a nearby kitchen cabinet. LPA Ramirez observed food debris on inside on refrigerator. Kitchen floors were observed to contain black and brown stains and unknown debris. Bottom floor of inside refrigerator was observed to contain brownish and yellow stains. Walls near kitchen stove were observed to have unknown black and brown spatters. Kitchen area was malodorous. Water temperature in kitchen sink was measured at 102.3 degrees F.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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 9
Document Has Been Signed on 07/31/2023 04:51 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/31/2023 at 01:07 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: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)
Building 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, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, insects crawling on bagged food, dead insects under kitchen sink, insects seen crawling in client bedroom flies seen in kitchen and living room, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will hire exterminator and provide LPA Ramirez with pest control contract to eradicate insects and flies. Licensee will provide monthy updates for the next four months (DECEMBER of 2023) from pest control on facility progress. Updates will be provided via email by the 30th of every month to LPA Ramirez.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, disinfectant spray and cleaning solutions were observed to be accessible in shared client bathroom #2, the licensee did not comply with the section cited above in out 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will keep all disinfectants and cleaning solutions inaccessible to clients. Licensee re-train staff on the importance of safe guarding these chemicals. Licensee will provide a plan on training by 8/1/23. Proof of staff training attendance must br provided via email by 8/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 07/31/2023 04:51 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/31/2023 at 01:07 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: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water in client bathroom #1 and 2 were not within the required 105 - 120 degrees F, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will adjust temperature accordingly. Licensee will develop water log and record temperatues for the next 7 calendar days and email proof to LPA Ramirez by 8/7/23. Water must be checked every 24hours and logged.
Type A
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, S1 could not fully communicate with LPA Ramirez on questions regarding client care and facility information, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will develop plan to address competent staff concerns.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/31/2023 04:51 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/31/2023 at 01:07 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: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C5 did not have medical assessment in file, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will develop plan to address lack of medical assessemnt of C5. Licensee will submit medical assessment by 8/7/23 via email.
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, C5 did not have results of communicable tuberculosis and other contagious/infectious diseases in C5's file, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will develop plan to address lack of result of TB test of C5. Licensee will submit C5 TB test result by 8/7/23 via email.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/31/2023 04:51 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/31/2023 at 01:07 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: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, insects were seen crawling on vegatables that were being stored on back porch, pantry closet was observed to have insects crawling inside, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will store food for consumption in a clean area. Licensee will clean pantry closet. Licensee will send photo proof by 8/1/23 via email.
Type A
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, green leaf lettuce was observed to be brown and wilted and sitting on kitchen counter next to a bag of bread, the licensee did not comply with the section cited above in 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2023
Plan of Correction
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Licensee will re-train staff food contamination. Licensee will provide plan on how to address training. Proof of staff attendance is due by 8/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/31/2023 04:51 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/31/2023 at 01:07 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: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:  (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in client care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, window coverings in client bedrooms were dusty, the licensee did not comply with the section cited above in 5 out of 5 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Licensee will clean and dust all window coverings and send picture proof by 8/7/23.
Type B
Section Cited
CCR
80087(a)
Building 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, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, facility hallway walls were dirty and facility was malodorous, the licensee did not comply with the section cited above in 5 out of 5 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Licensee will clean hallway walls and send picture proof to LPA via email. Licensee will address how the facility plans to address malodorous smell in facility via email by 8/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/31/2023 04:51 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/31/2023 at 01:07 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: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(e)
Administrator Qualifications and Duties
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA Ramirez and S1 could not make contact with Administrator for 4 hours or facility house manager, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Licensee will develop a plan to address how facility staff and visitors can make contact with Licensee/Administrator during regular business hours.
Type B
Section Cited
CCR
85076(d)(4)
Food Service
(4) Freezers and refrigerators shall be kept clean, and food storage shall permit the air circulation necessary to maintain the temperatures specified in (2) and (3) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, freezer had lock, duck tape and packing tape and was observed to be dirty, the licensee did not comply with the section cited above in 5 out of 5 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Licensee will remove lock and clean refrigerator. Licensee will send picture proof by 8/7/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME AND CARE II
FACILITY NUMBER: 197802313
VISIT DATE: 07/31/2023
NARRATIVE
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Living room: Living room was observed plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in nearby area. Windows area were observed to be dusty. LPA Ramirez observe several flies in this area. Livingroom was observed to be malodorous.

Linen Closet: Hallway near linen closet area were smeared with dark stains. Contained plenty linens, towels, and hygiene products.

Client Rooms 1 - 3: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting. Bedroom#1 is shared but currently only housing one client at this time. Bedroom #2 is shared. LPA Ramirez counted seventeen (17) plastic bags that contained garments and unknown items in front of C2’s closet. LPA Ramirez observed this area to be cluttered. LPA Ramirez observed over 10 books on a nearby dresser and saw insects crawling on C1’s books. Window coverings were observed to be dusty in all client bedrooms. Client bedroom #3 window screen had a quarter size hole and was observed to be dusty. All client bedrooms were observed to be malodorous.

Bathrooms: Water temperature in shared bathroom#1 was measured at 100.4 degrees F which is not within the required 105 – 120 degrees F. LPA Ramirez observed a non-slip mat in this shower. Shared bathroom #2 water temperature was measured at 99.7 degrees F which is not within the required 105 – 120 degrees F. LPA Ramirez observed non-slip mats in this shower. LPA Ramirez observed half full bottle of “Clorox” cleaning spray and half full bottle of “Fabuloso” multi cleaner disinfectant.

Centrally Stored Medications: LPA Ramirez observed centrally stored medications cabinet to be located in staff #1 bedroom. Cabinet was locked and inaccessible to five (5) clients in care.

Backyard: No large bodies of water were observed.

Emergency Drills (Conducted every 6 months): Proof of last documented fire drill was conducted 2/12/23.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME AND CARE II
FACILITY NUMBER: 197802313
VISIT DATE: 07/31/2023
NARRATIVE
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Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files were maintained at facility. LPA Ramirez reviewed one (1) staff file. LPA Ramirez was having difficulty communicating with LPA Ramirez. S1 appeared to be confused at questions LPA had and at one point during the interview process, C1 attempted to step in and help S1 by serving as an interpreter. S1 was unable to comprehend was an “Infection Control Plan” was and where it was located. LPA Ramirez was uable to view current Administrator certificate. From 9 am to 11:45 am, LPA Ramirez and S1 were unable to contact Licensee/Administrator. Facility house manager (S2) was also not available after multiple attempts to contact during visit.

Client Files: Five (5) client files were reviewed. Admissions agreements, resident personal rights, medical assessments were observed for four (4) out of five (5) clients in care. C5 file did not contain medical assessment and screening for Tuberculosis.

Infection Control Plan: Infection Control Plan will be provided via email within 7 business days.

Deficiencies are being cited. Exit interview was conducted S1 and a copy of this report, 8Document Link Icon09-D, and appeals rights were provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC809 (FAS) - (06/04)
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