198202004-9-1-2022-11-AS-ASOO-CHLV89-20220824161222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198202004
Report Date: 08/24/2022
Date Signed: 09/01/2022 08:48:05 AM

Document Has Been Signed on 09/01/2022 08:48 AM - 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ANGELS HOME CARE		FACILITY NUMBER:	198202004
ADMINISTRATOR:	ANA GUTIEREZ LECHUGA		FACILITY TYPE:	740
ADDRESS:	28030 ACANA RD		TELEPHONE:	(310) 265-4994
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 3	DATE:	08/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Vicenta Mendoza, Licensee		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met with Vicenta Mendoza, Licensee and the purpose of today’s visit was explained.

There are currently (3) residents in the facility. (0) residents are ambulatory, (3) are non-ambulatory, () bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (3) bedrooms, (2) bathrooms, shaded back yard, front yard, fountain in front yard not being used, laundry room, and an attached garage.

LPA and Oscar toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1& 2 are occupied by residents and contain the mandated furniture. Bedroom 3 is vacant. The (2) bathrooms are operational but need to be de-cluttered. Bathroom #2 shower is not used and is being as a storage for diapers, toxins, and boxes. Bathroom #1 is operational , but needs to be de-cluttered: it has too many shower chairs and mobile toilets and mobile toilets are dirty. Kitchen table is full of papers, no room to eat. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is 105.6 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways have debris: west side passageway of facility contains, broken wood door, paints cans, trash bags, pots, bricks, umbrellas, mini pool, mop cans, which need to be removed. East side passageway has more debris: it's being as storage for licensee, items must be removed and/or stored. Front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS HOME CARE	FACILITY NUMBER: 198202004
	VISIT DATE: 08/24/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in cabinet near living room. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, No mitigation plan posted and/or in binder, No Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & computer for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued citations.

Technical Advisories (TA) issued. No mitigation Plan posted and/or in binder, No Fit Testing completed for staff.

A exit interview was conducted with Vicenta Mendoza, and a hard copy and Appeal Rights provided

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/01/2022 08:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS HOME CARE	FACILITY NUMBER: 198202004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87303(a)(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This was not met as evidence by: The (2) bathrooms are operational but need to be de-cluttered. Bathroom #2 shower is not used and is being as a storage for diapers, toxins, and boxes. Bathroom #1 is operational , but needs to be de-cluttered: it has too many shower chairs and mobile toilets and mobile toilets are dirty. Kitchen table is full of papers, no room to eat.Which poses a health and safety risk for persons in care.
	POC Due Date: 09/15/2022
	Plan of Correction
1 2 3 4	Administrator will remove and/or store items and will take pictures of both bathroom and send it to LPA Soto on or before due date.

Section Cited


	Deficient Practice Statement
1 2 3 4	87307(d)(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This was not met as evidence by: Based on west side passageway of facility contains, broken wood door, paints cans, trash bags, pots, bricks, umbrellas, mini pool, mop cans, which need to be removed. East side passageway has more debris: it's being used as storage for licensee, items must be removed and/or stored. Which pose health ans safety risk for persons in care
	POC Due Date: 09/15/2022
	Plan of Correction
1 2 3 4	Administrator will remove and/or store items and will take pictures of both bathroom and send it to LPA Soto on or before due 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

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