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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204584
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:27:12 PM


Document Has Been Signed on 02/29/2024 03:27 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:VILLA ANGELA RESIDENTIAL HOMEFACILITY NUMBER:
198204584
ADMINISTRATOR:SHIRLEY DANTINGFACILITY TYPE:
740
ADDRESS:23528 FIGUEROA STREETTELEPHONE:
(310) 835-6773
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 6DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Shirley DantingTIME COMPLETED:
03:57 PM
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On 02/29/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with licensee Shirley Danting and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for (4) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (5) residents' rooms, (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA and licensee toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 116.1 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (1) fire extinguisher that was charged, smoke detectors, and carbon monoxide were operable. LPA reviewed Medication Administration Records (MAR) revealed accurate and maintained in order. The facility conducted a Fire/Safety Drill on 02/09/24. A working landline telephone remains available.

Evaluation Report Continues on LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: VILLA ANGELA RESIDENTIAL HOME
FACILITY NUMBER: 198204584
VISIT DATE: 02/29/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted.

An audit of residents #1-#6 (R1-R6) service records and staff #1-#4 (S1-S4) personnel records revealed to be complete. The facility has a current liability insurance coverage effective 06/23/23 through 06/23/24. The facility is current on CCL annual dues. The facility has a current administrators certificate for Shirley Danting # 6071726740 expiration 07/25/24.

No deficiencies cited during this inspection visit.

An exit interview conducted with Shirley Danting and a copy of the report is provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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