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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600180
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:55:18 PM

Document Has Been Signed on 06/02/2023 12:55 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
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: 6DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Flordeliza Rosana, CaregiverTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Caregiver Flordeliza Rosana and explained the purpose of the visit. Administrator Adelina Esguerra was explained the purpose of the visit telephonically. There are five (5) ambulatory mentally disabled clients ages 59 and under.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and COVID-19 screening is still in place. A screening station is located in the main entrance. Personal Protective Equipment (PPEs) were observed. An Infection Control Plan has not been submitted. A citation was issued.


Physical Plant/Environment Safety:
  • 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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180
VISIT DATE: 06/02/2023
NARRATIVE
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Operational Requirements:
  • The Program Design was reviewed.
  • Fire clearance was approved for six (6) non-ambulatory clients.
  • Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
  • Surety Bond is not applicable. Clients handle their own money.

Staffing:
  • A total of four (4) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 3/26/2023. Training was submitted to the recertification unit.
  • Three (3) staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings and 1st Aid/CPR training, but no current staff training was on file. Citation was issued.

Client Rights/Information:
  • Physician orders for postural supports and devices are not applicable.

Client Records/Incident Reports:
  • Four (4) client files were reviewed containing admission agreements, Physician's Reports, medical/functional assessments, Needs and Services Plans, TB clearance, personal rights, medical consent, medication records, and Restricted Health Care Plans. No P& I records are applicable.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • Three (3) clients have Physician orders for a modified Diabetic diets on file. One (1) month supply of food was observed.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180
VISIT DATE: 06/02/2023
NARRATIVE
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Four (4) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental:
  • All clients have a Needs and Services Plan and COVID-19 vaccination cards on file.
  • Current staff training was not on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610 was on file. However, the facility does not have the required LIC 610D forms. Citation was issued.
  • An emergency drill held at least every 6 months was conducted on 1/21/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.


Per California Code of Regulations, Title 22, deficiencies are being cited.

Exit interview conducted with 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: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/02/2023 12:55 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/02/2023 at 11:17 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: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff files did not contain any proof of staff training in the past several years; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator shall conduct required training to all staff. Submit a copy of the training log with topic and staff signatures.
Type B
Section Cited
CCR
80023(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in thatAdministrator does not have the current LIC 610D "Emergency and Disaster Plan"; which poses a potential health, safety or personal rights risk to persons in care.

POC Due Date: 06/16/2023
Plan of Correction
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Administrator shall submit a copy of LIC 610D by POC due date and keep in file at the facility.
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: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2023 12:55 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/02/2023 at 11:54 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: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(A-F)
INFECTION CONTROL REQUIREMENTS. An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. The Infection Control Plan shall include all of the following: Identification of a staff position to perform the duties of an Infection Preventionist for the facility. (B) A description of how the licensee shall meet the specific infection control practice requirements of subsections (a), (b) and (d). An Infection Control Training Plan. The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. The licensee shall ensure that staff encourage clients to follow infection control practices as necessary.Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Administrator never submitted the infection control plan to CCL as required; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator agreed to develop and submit a copy of the Infection Control Plan.

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: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


LIC809 (FAS) - (06/04)
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