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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802313
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:55:09 PM

Document Has Been Signed on 02/13/2024 04:55 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:
02/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff#1 (S1) caregiverTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit during the complaint visit 28-AS-20240205143121. LPA met with Staff#1 (S1), staff at the facility and spoke with Staff#2 (S2) house manager Shirley Esguerra, over the phone. The purpose of the visit was to check on the Health and Safety of the residents and facility. The purpose was discussed with house manager. On today’s visit, LPA conducted a health and safety check. LPA toured the physical plant of the facility and staff file reviews. LPA obtained a copy of the staff/ client roster.

LPA reviewed clients' records from client#1 to client#5, and observed clients' files were incomplete which were missing one or multiple forms/documents listed below:
· I.D. and emergency information (facesheet)
· Physician report
· TB test result/document
· Appraisal & needs service plan
· Immunization records
· Consent form
· Centrally stored Medication Destruction records
· Safeguards for Cash resources (P&L if handling client’s money at the facility)
· Safeguards for Property / Valuables
· Personal rights (LIC 613, LIC 613B or LIC 613C)
· Cash resources information (if handling client’s money at the facility)

Deficiencies of Health and Safety were observed per Title 22 Regulations Division 6 Chapter 8. Exit interview was conducted with staff#1 and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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 02/13/2024 04:55 PM - It Cannot Be Edited


Created By: Bonnie Tao On 02/13/2024 at 04:06 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: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2024
Section Cited
CCR
80070(a)

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The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement was not met as evidenced by:
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Administrator would obtain current clients documents to complete clients records and maintain records at the facility. Administrator would ensure clients’ records were available for reviews all time. POC is due on 2/21/24.
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Administrator did not maintain a current and complete clients files from C1 to C5 at the facility.

Based on file review, Administrator did not comply with the section cited above which 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:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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