198205039-7-11-2023-11-AS-ASOO-CLRVCR-20221203151933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205039
Report Date: 12/03/2022
Date Signed: 07/11/2023 08:13:42 AM

Document Has Been Signed on 07/11/2023 08:13 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:	ANGEL'S HAVEN II		FACILITY NUMBER:	198205039
ADMINISTRATOR:	OSCAR LECHUGA		FACILITY TYPE:	740
ADDRESS:	28022 ACANA ROAD		TELEPHONE:	(310) 544-4594
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS:	DATE:	12/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:54 PM
MET WITH:	Vicenta Mendoza, Administrator		TIME COMPLETED:	04:00 PM

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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, Administrator and the purpose of today’s visit was explained.

There are currently (5) residents in the facility. (1) residents are ambulatory, (4) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (3) bedrooms, (2) full bathrooms, living room, dining room, kitchen, shaded back yard, front yard, laundry room and attached 2 car garage.

LPA and Vicenta toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. Smoke detectors and carbon monoxide detector were in compliance and operational. Medications are stored, locked and inaccessible to residents. Ample supply of perishable and nonperishable food and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents. Exit, walkways and/or passageways, 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: 12/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2022

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: ANGEL'S HAVEN II	FACILITY NUMBER: 198205039
	VISIT DATE: 12/03/2022

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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 the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPhone 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. All residents and staff are vaccinated and boosted

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Technical Advisories (TA) issued.

1. Mitigation Plan

2. Fit Testing

An exit interview conducted with Vicenta Mendoza, Administrator and a hard copy of report provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2022

LIC809 (FAS) - (06/04)

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