198600067-9-17-2021-11-AS-UCOL-C6QR4F-20210910124127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600067
Report Date: 09/10/2021
Date Signed: 09/17/2021 08:57:23 AM

Document Has Been Signed on 09/17/2021 08:57 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:	ANGELICA GUEST HOME		FACILITY NUMBER:	198600067
ADMINISTRATOR:	MARCELO E. MENDOZA		FACILITY TYPE:	735
ADDRESS:	12613 LONG BEACH BLVD		TELEPHONE:	(310) 639-4719
CITY:	LYNWOOD	STATE: CA	ZIP CODE:	90262
CAPACITY: 48		CENSUS: 48	DATE:	09/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Diogenes Valencerina		TIME COMPLETED:	12:58 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Diogenes Valencerina, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve clients age range 18 through 59. approved to serve up to 12 non-ambulatory clients. There are currently 29 South Central Regional Center consumers in placement. Of which 12 clients are non-ambulatory. The facility is located in a commercial business area, the facility consisted of: a lobby, main office, visitor room, TV room, kitchen, dining room, medication room, 24 bedrooms, 17 bathrooms, pantry, laundry room, 3 bedroom apartment for staff is located above laundry room, shaded area, indoor/outdoor activity areas. LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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 105.1F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

Document Has Been Signed on 09/10/2021 12:41 PM - It Cannot Be Edited

Created By: Ulysses Coronel On 09/10/2021 at 11:58 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: ANGELICA GUEST HOME	FACILITY NUMBER: 198600067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)(1)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above During todays visit LPA observed that the cleaning supply cabinet was unlocked and accessible to clients in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2021
	Plan of Correction
1 2 3 4	The administrator agreed to conduct an in service training on 80087(g)(1) Buildings and Grounds, proof of Correction will be submitted by POC due date.

Type B

Section Cited

CCR

85102(b)(5)

Emergency Intervention Prohibitions Manual restraint or seclusion shall not be used: To prevent a client from leaving a room or area or the facility when there is no immediate threat to health and safety of the individuals or others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2021
	Plan of Correction
1 2 3 4	This was corrected during today's visit, the administrator removed the child lock from the door handle. An in service training will conducted on 85102(b)(5) Emergency Inteervention Prohibitions.

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Ulysses Coronel

LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: ANGELICA GUEST HOME	FACILITY NUMBER: 198600067
	VISIT DATE: 09/10/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During todays visit LPA observed that the cleaning supply cabinet was unlocked and accessible to clients in care.

During todays visit LPA observed that a child lock was installed at the door leading into the lobby area.

During today’s visit there were deficiencies cited please see LIC9099D

Exit interview held. A copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC809 (FAS) - (06/04)

Page: 6 of 6