198203450-1-8-2024-11-AS-RCLD-CZARN5-20240108120947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203450
Report Date: 01/08/2024
Date Signed: 01/08/2024 12:10:03 PM

Document Has Been Signed on 01/08/2024 12:10 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:	ANGEL CARE IV		FACILITY NUMBER:	198203450
ADMINISTRATOR:	MAGPILE, MYLENE		FACILITY TYPE:	740
ADDRESS:	627 N. PAULINA AVE.		TELEPHONE:	(310) 372-0674
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90277
CAPACITY:	6	CENSUS: 6	DATE:	01/08/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Licensee Mylene Magpile		TIME COMPLETED:	12:30 PM

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On 01/08/2024 at 8:23 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with staff Joy Black. Licensee Mylene Magpile joined us 45 minutes later. Six (6) residents and three (3) staff were present during this inspection.

Facility is licensed to serve licensed to serve six (6) non-ambulatory elderly residents ages 60 and above. Facility may accept or retain six (6) residents on hospice.

The one-story residential house consists of six (6) resident bedrooms, kitchen, dining area, living room, three (3) residents bathrooms, staff quarter (located in the back of the house), garage, washer/dryer located in garage, and backyard with a shaded patio, front landscape and yard was well maintained at time of visit.

Joy accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or 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, hot water temperature properly measured at 113F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, 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. Two fire extinguishers, last serviced March 20, 2023 was observed in the kitchen and garage area. Staff tested carbon monoxide detectors and smoke detector located in the living room. Both devices were functional.

Continue to LIC-809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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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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: ANGEL CARE IV	FACILITY NUMBER: 198203450
	VISIT DATE: 01/08/2024

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5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Two staff interviews were conducted.

5 resident records were reviewed and, 5 out of 5 client records had medical assessments and Needs and Services Plans. Two residents’ medication was reviewed.

No deficiencies are being cited.

An exit interview was conducted and technical assistance provided. A copy of this report was discussed and left with the Licensee.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC809 (FAS) - (06/04)

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