198202004-8-10-2024-11-AS-RCLD-D7ZTHZ-20240810144535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198202004
Report Date: 08/10/2024
Date Signed: 08/10/2024 02:45:49 PM

Document Has Been Signed on 08/10/2024 02:45 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
EL SEGUNDO ASC, 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: 5	DATE:	08/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Licensee Vicenta Mendoza		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 08/10/24 at 9:10 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Licensee Vicenta Mendoza.

This facility is licensed to serve 6 adults ages 60 and above, of which 4 may be non-ambulatory residents. Facility must maintain a 24-hour awake staff. Facility is approved for 6 hospice residents. The facility currently has one resident on hospice.

The facility is a one-story house located on a residential street. The home consists of 3 resident bedrooms, 1 staff bedroom, 2 bathrooms, 1 dining/living room, 1 kitchen, 1 attached garage, and a front yard and backyard patio area with shaded seating.

The Licensee accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured at 109.2 degree F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024

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 08/10/2024 02:45 PM - 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS HOME CARE	FACILITY NUMBER: 198202004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for four out of five staff members which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe 20 hours of annual training for Staff #1, #3, #4, and #5.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	The Administrator will email a training plan that is aligned with HSC 1569.625(b)(2) to regina.cloyd@dss.ca.gov by the POC due date. The training plan overview should include the topics, anticipated hours, and months it will be delivered.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS HOME CARE	FACILITY NUMBER: 198202004
	VISIT DATE: 08/10/2024

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Common areas were clean and clear of hazards and doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced January 10, 2024 was observed in the kitchen area. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

5 staff records were reviewed.

5 resident records were reviewed and 5 out of 5 resident records had admission agreements. Two residents’ medication was reviewed.

Deficiencies are being cited based on LPA’s record review in accordance with the California Code of Regulations, Title 22, see LIC809D. LPA did not observe 20 hours of annual training for staff #1, #3, #4, and #5.

An exit interview was conducted, plans of correction developed, technical assistance provided, and a copy of this report was discussed and left with Licensee Vicenta Mendoza.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024

LIC809 (FAS) - (06/04)

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