198320274-1-3-2024-11-AS-FSHY-CZ5S6U-20240103123633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320274
Report Date: 01/03/2024
Date Signed: 01/03/2024 12:36:39 PM

Document Has Been Signed on 01/03/2024 12:36 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ANGEL HOUSE, THE		FACILITY NUMBER:	198320274
ADMINISTRATOR:	JOHNSON, SOPHESIAS		FACILITY TYPE:	735
ADDRESS:	5103 W. 123RD PLACE		TELEPHONE:	(562) 405-7316
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 3		CENSUS:	DATE:	01/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Wallis Caiquo		TIME COMPLETED:	12:40 PM

NARRATIVE

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On 01/3/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Annual required visit with a primary focus on infection control measures, using the new Care Inspection Tool. LPA was met by Co- Administrator, Wallis Caiquo and the purpose of today’s visit was explained. Todays census is 1.

The facility is a single-story home in a residential neighborhood. The facility consists of 3 bedrooms, 2 bathrooms, a living room, dining room and kitchen.

LPA Shirley and Wallace walked through the kitchen and all appliances were in good working order. Knives were locked and stored in the cabinet in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 112 degrees Fahrenheit.

There are three (3) resident rooms. Each room had the required furnishings including bed, nightstand with a lamp, and chair. All beds have the required linens including fitted sheets, blanket, comforter and pillow. All rooms have ample closet space and lighting.

All bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly. The showers were free of mildew and mold.

LPA Shirley and Wallace walked through all common areas. In the living room, kitchen, dining room there is ample seating and space residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen.

Documents are posted as mandated. First aid kit is fully stocked with manual. 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. The facility is in good repair.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL HOUSE, THE	FACILITY NUMBER: 198320274
	VISIT DATE: 01/03/2024

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LPA did not have access to staff files. LPA spoke with Administrator Sophesias Johnson and was told files are being updated and would not be available in time to complete annual. Deficiencies are being cited based on interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D.

An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with Co-Administrator Wallis Caiquo whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/03/2024 12:36 PM - It Cannot Be Edited

Created By: Felisa Shirley On 01/03/2024 at 11:28 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ANGEL HOUSE, THE	FACILITY NUMBER: 198320274
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

80066(c)

Personnel Records (c) All personnel records shall be available the licensing agency to inspect, adudit and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in which not having records of staff working with clients poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2024
	Plan of Correction
1 2 3 4	Licensee must keep employee/staff files readily available for review upon demand during normal business hours.

Type B

Section Cited

HSC

80019(e)(2)

Criminal Record Clearance 80019 (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility (2) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in which hiring staff without clearance poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2024
	Plan of Correction
1 2 3 4	Licensee must have staff fingerprinted and background cleared for employment.

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:

Stephanie Cifuentes

LICENSING EVALUATOR NAME:

Felisa Shirley

LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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