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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802313
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:39:26 PM

Document Has Been Signed on 06/14/2024 03:39 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/
DIRECTOR:		ESGUERRA, ADELINAFACILITY TYPE:
735
ADDRESS:622 N. WATERBURY AVENUETELEPHONE:
(626) 257-3245
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 5DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Lucita Atanacio, caregiver
Shirely Esguerra, house manager		TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection. LPA met with caregiver, Lucita Atanacio and Shirley Esguerra, house manager and discussed the purpose of today's visit. The facility is licensed to serve six (6) mentally disable ambulatory only clients, from age 18-59. Facility annual fees were current. Administrator certificate is current and expires on 05/26/25.

For today's annual visit, CARE tools were applied, physical plant was conducted, staff/clients were interviewed, and food supply/medications/medication records/staff files/clients files were reviewed.

Facility was a single family 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. Bathrooms were clean and operable. Facility maintained the required two (2) days perishable food and seven (7) days non- perishable food. Clients’ bedrooms had the required furniture and in compliance. Adequate linen and personal hygiene supply were observed. Smoke detectors and carbon monoxide detectors were operable. Medications were centrally stored and locked. Fire extinguisher was fully charged. Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored. A shaded area with chairs was provided in the rear.

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

An exit interview was conducted. This report is discussed and provided to Shirley Esguerra, house manager, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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 06/14/2024 03:39 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/14/2024 at 02:43 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: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
On 06/14/24, client #1’s morning medication Duloxetine Hcl Dr 60 mg was short one pill from the bubble package compared to medication record. Medication had a discrepancy with the number of pills and medication log.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
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Licensee agreed to provide (1) additional medication administration assistance training to all staff and provide proof to the department; (2) review Title 22, Section 80075(b) and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date
Type A
Section Cited
CCR
80087(g)
(g)…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:
Knives and sharp items were accessible to clients and were not locked in a lock container.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2024
Plan of Correction
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Licensee agreed to lock the sharp items and provide training to staff to ensure those items were not accessible to clients by the POC date.
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: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2024 03:39 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/14/2024 at 03:20 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: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(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 was not met as evidenced by:
Spiders and spider webs were observed in food pantry, kitchen and bathroom.
Stove top's 2 front burners were not operational.
A floor tile in the bathroom located next to the bathtub was loosen and broken.
A countertop tile in the kitchen sink was chipped at the edge.
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: 06/28/2024
Plan of Correction
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Licensee agreed to conduct a deep clean of the house and repair the broken items. Administrator will provide pictures of those items for the proof of correction to Licensing by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
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