198600067-9-11-2024-11-AS-HENZ-D8ZVH6-20240911162636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600067
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:26:53 PM

Document Has Been Signed on 09/11/2024 04:26 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ANGELICA GUEST HOME		FACILITY NUMBER:	198600067
ADMINISTRATOR/ DIRECTOR:	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: 24	DATE:	09/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator Diogenes Valencerina		TIME VISIT/ INSPECTION COMPLETED:	04:45 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	On 09/11/2024 at around 9:00AM, Licensing Program Analysts (LPAs) Enriquez and Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility. LPAs met with Administrator Diogenes Valencerina and the purpose of the visit was explained. This facility is licensed to serve forty-eight (48) adults ages 18 – 59 years with developmental disabilities, of which 12 clients may be non-ambulatory. Currently there are a total of 24 clients, of which 7 clients are non-ambulatory. Per record review, the Annual Licensing Fees are current. Administrator accompanied LPAs on a tour of the outside and inside of the facility grounds. The facility is a two-story building located on a commercial street. The facility consists of a lobby, main office, visitor room, TV room, kitchen, dining and living room, medication room, 24 bedrooms, 17 bathrooms, 1 common shower/bath for men and 1 for women, a pantry, a laundry room and several storage rooms. There is an outdoor activity area with shaded seating. Continued on 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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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Document Has Been Signed on 09/11/2024 04:26 PM - It Cannot Be Edited

Created By: Hollie Enriquez On 09/11/2024 at 03:28 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ANGELICA GUEST HOME	FACILITY NUMBER: 198600067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(a)(7)(A)

80072 Personal Rights(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(7)Not to be locked in any room, building, or facility premises by day or night.(A)The licensee shall not be prohibited by this provision from locking exterior doors and windows or from establishing house rules for the protection of clients provided the clients are able to exit the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations the licensee did not comply with the section cited above in having an emergency exit door facing Long Beach Blvd. chained and locked which poses/posed a potential safety and personal rights risk to persons in care.
	POC Due Date: 12/03/2024
	Plan of Correction
1 2 3 4	The licensee removed the chain and lock from the emergency exit door during the time of the visit. Licensee has a plan to replace the emergency exit door. The Licensee agrees to contact contractors, local fire department, and to develop a timeline and a plan to ensure the safety of clients in care during this renovation process. The Licensee will email proof of corrections to Hollie.Enriquez@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Hollie Enriquez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ANGELICA GUEST HOME	FACILITY NUMBER: 198600067
	VISIT DATE: 09/11/2024

NARRATIVE

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Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises.

LPAs toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPAs 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 drills were conducted on 09/06/2024. County of Los Angeles Fire Department conducted an official inspection on 07/03/2024 an no violations were found. First aid kit is fully stocked with manual. Several fire extinguishers were observed in the facility, and they were last serviced on 11/12/2023. There are 2 videoconferencing devices dedicated for client use in the main office. LPAs observed that the emergency exit door by room 118 was chained and locked and Administrator removed the chain and lock during the visit.

Continued on 809C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ANGELICA GUEST HOME	FACILITY NUMBER: 198600067
	VISIT DATE: 09/11/2024

NARRATIVE

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Several clients’ bedrooms were checked. Mattresses were in good condition, adequate lighting, adequate dresser, and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linens, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Sufficient lighting and toiletries were accessible to clients. LPAs tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides clients with hygiene products such as feminine napkins, non-medicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 client records were reviewed and, 5 out of 5 client records had required documentation.

A deficiency is being cited based on LPAs observations in accordance with the California Code of Regulations, Title 22, see LIC809D; a violation regarding Personal Rights due to the locking of an exit door. LPAs discussed and developed a Plan of Correction with the Administrator.

An exit interview was conducted and copy of this report and appeal rights have been left with Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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