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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600067
Report Date: 09/08/2023
Date Signed: 09/08/2023 04:17:12 PM

Document Has Been Signed on 09/08/2023 04:17 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:ANGELICA GUEST HOMEFACILITY NUMBER:
198600067
ADMINISTRATOR:MARCELO E. MENDOZAFACILITY TYPE:
735
ADDRESS:12613 LONG BEACH BLVDTELEPHONE:
(310) 639-4719
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 48CENSUS: 25DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Orlando MagatTIME COMPLETED:
04:20 PM
NARRATIVE
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On 9/8/2023, Licensing Program Manager (LPM) Ulysses Coronel & Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with administrator Orlando Magat. LPM & LPA explained the purpose of the visit and were accompanied by administrator, inside and outside the facility during this inspection.

The facility is licensed to serve up to 48 developmentally disabled clients age range 18 through 59; and approved to serve up to 12 non-ambulatory clients.

There are currently (25) South Central Regional Center consumers in placement. The facility is 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, and laundry room. There is also a shaded area and indoor/outdoor activity areas for the clients.

LPM, LPA and the administrator toured the facility. LPA interviewed 3 staff and 3 client.

Due to time constraints an unannounced Case Management - Annual Continuation visit will be conducted.

Deficiencies are being cited based on LPA observations and interviews accordance with the California Code of Regulations, Title 22, see LIC809D.



An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with administrator Orlando Magat.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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Document Has Been Signed on 09/08/2023 04:17 PM - It Cannot Be Edited


Created By: Socorro Leandro On 09/08/2023 at 03:32 PM
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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the LPA observed doors in room number 121 doors were in disrepair.
During todays visit LPA observed large sliding (window) door with tape around the edges and with a sign stating "Do Not Use OR OPEN Sliding Door Broken Thank You" in room 108. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2023
Plan of Correction
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Licensee will repair doors and submit proof of correction via email to Socorro.Leandro@dss.ca.gov.
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
Deficient Practice Statement
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The licensee did not comply with the section cited above, based on observation the LPA observed the presence of cockroaches in the kitching floor, LPA also observed cockroach droppings beneath the kitchen stove, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2023
Plan of Correction
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The licensee will create a plan and create measures to be taken ensuring that the facility is free from cockroaches. Proof of correction will be submited via email to Socorro.Leandro@dss.ca.gov. An unannoced visit may be conducted to verify correction.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
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