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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600067
Report Date: 09/20/2023
Date Signed: 09/20/2023 05:16:59 PM

Document Has Been Signed on 09/20/2023 05:16 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:
09/20/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Orlando MagatTIME COMPLETED:
05:30 PM
NARRATIVE
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On 9/20/2023, LPM & LPA conducted an unannounced Case Management – Annual Continuation Visit 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.

During todays visit, LPM & LPA observed that medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 09/05/2023. Five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Five (5) client records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. LPM & LPA reviewed P&I money, 5 out of 5 residents P&I were intact and were not commingled with facility funds or petty cash.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding Physical Plant that was cited within the last 12 months warrants civil penalty assessment for a repeat violation.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report , civil penalty assessment and appeal rights were discussed and left with administrator Orlando Magat.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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 09/20/2023 05:16 PM - It Cannot Be Edited


Created By: Socorro Leandro On 09/20/2023 at 04:32 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: 09/20/2023

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

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interview, the licensee did not comply with the section cited above during todays visit. LPA observed that the door nob at room 121 is in disrepair and missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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The licensee will repair the door and update the IPP of resident C5 to address escalation of clients destruction of property. Proof of correction will be emailed to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
80087
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.

This requirement was not met as evidence by
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above during todays visit LPA observed the presence of bleach and detergent in the laundry area accesible to client C4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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During todays visit the administrator ensured that the bleach and detergent were locked away inaccessible to clients. The administrator will conduct staff training to ensure future compliance. Proof of correction will be emailed to Socorro.Leandro@dss.ca.gov
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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023


LIC809 (FAS) - (06/04)
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