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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600180
Report Date: 05/05/2022
Date Signed: 05/06/2022 09:19:03 AM

Document Has Been Signed on 05/06/2022 09:19 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ANGELINA HOME AND CARE IIIFACILITY NUMBER:
198600180
ADMINISTRATOR:ADELINA B. ESGUERRAFACILITY TYPE:
735
ADDRESS:3036 LA PUENTE ROADTELEPHONE:
(909) 598-8323
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Flordeliza Rosana, StaffTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Flordeliza Rosana and explained the purpose of the visit. There are five (5) ambulatory mentally disabled clients ages 59 and under. Facility is a single story home located in a residential area consisting of 3 client bedrooms, 1 staff room, 2 bathrooms, kitchen/dining area, living room, attached garage with laundry area, and covered patio area. The last fire drill was completed on 4/23/22. Administrator certificate expires 3/26/2023.

The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed upon entry and in common areas.
  • Infection control signs, and other signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. PPEs were observed.
  • Facility does not have designated isolation room/area; protocol is to contact DMH and DPH.
  • All bedrooms and common areas have hand sanitizer. Residents are provided masks.
  • Five (5) centrally stored resident medication records were reviewed.
  • Staff responsible for direct care and supervision was observed wearing a mask.
  • Clients were not observed wearing masks in the home.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A Emergency Disaster Plan was not posted but provided upon request.
  • Light bulbs in both bathrooms are needed. A cover for the fluorescent light bulbs shall be installed.
  • The carbon monoxide detector on the wall was not operable. However, there was a brand new carbon monoxide detector with batteries that has not been installed. Smoke detector in room #1 needs batteries. A new smoke detector was observed, but needs to be installed. Technical Violation was issued.


Exit interview was conducted with staff Flordeliza Rosana. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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 05/06/2022 09:19 AM - It Cannot Be Edited


Created By: Noemi Galarza On 05/05/2022 at 11:14 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
BUILDINGS 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 licensee did not comply with the section cited above in that the backyard had discarded bed frames, furniture, and items stored in boxes in the patio area. The side yard had discarded wheelchair, bins, and ladder posing tripping hazards. Both bathrooms need lightbulbs and light covers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Administrator shall install lightbulbs in both bathrooms, and purchase a cover for the fluorescent bulbs. All discarded debris in the back and side yards shall be removed. Send picture proof of corrections by POC due date/
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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