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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600180
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:49:15 PM

Document Has Been Signed on 05/03/2024 01:49 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/
DIRECTOR:		ADELINA B. ESGUERRAFACILITY TYPE:
735
ADDRESS:3036 LA PUENTE ROADTELEPHONE:
(909) 598-8323
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:32 AM
MET WITH:Flordeliza Rosana, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to caregiver staff Flordeliza Rosana. The facility is an Adult Residential Facility (ARF) that serves mentally disabled residents ages 59 and under. It consists of 4 bedrooms [ 3 resident & 1 live-in staff room], 2 bathrooms, kitchen, dining room, living room, attached 2-car garage with laundry area, and outdoor patio area. The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility staff are using appropriate hand hygiene cleaning and disinfecting the home. An Infection Control Plan was reviewed.

Physical Plant/Environment Safety: 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 were tested and are operation. The facility has one (1) fully charged fire extinguisher. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

The stove burners are not in safe working condition because staff are using matches to ignite the burners. The backyard had discarded furniture, wood planks, boxes, and large tree sticks. The stucco on the right side and back of the house has large areas missing stucco. A citation was issued.

Two (2) beds did not have required mattress pads. A citation was issued.

Operational Requirements: The Program Design was reviewed. Fire clearance is 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.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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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: 05/03/2024
NARRATIVE
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Staffing: A total of three (3) staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Three (3) staff files were reviewed and contained criminal background clearance and CPR/First aid certificates. Administrator certificate expires 3/26/2025.

On-going staff training is not on file. Staff (S2 & S3) have not received training in years. A citation was issued. NOTE: Same citation was issued last year and not corrected.

Resident Rights/Information: Resident Personal Rights poster is posted in the facility. Internet access is available for clients. Physician's orders are on file.

Resident Records/Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Reports, medical/functional assessments, Needs and Services Plans, TB clearance, personal rights, medical consent, and medication records. No P& I records are applicable.

Resident (R1) is missing a medical assessment. A citation was issued.

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. The facility has 3 refrigerators and 1 freezer.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Five (5) 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 residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: A current LIC 610D updated form "Emergency Disaster Plan/Disaster and Mass Casualty Plan LIC 610D was not provided. The same citation was issued last year and not corrected. A citation was issued.

The last Fire/Emergency Drill was conducted on 4/14/2024.

Emergency Intervention: No manual restraints, seclusion, or de-escalation techniques are used.

Per Title 22, California Code of Regulations, deficiencies were cited.


Exit interview with caregiver staff Flordeliza Rosana was conducted. A copy of the report/appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/03/2024 01:49 PM - It Cannot Be Edited


Created By: Noemi Galarza On 05/03/2024 at 01:09 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 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: 05/03/2024

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 licensee did not comply with the section cited above in that the stove burners are not in working condition, backyard had discarded furniture, wood planks, boxes, large tree sticks, and the stucco on the right side and back of the house has large areas missing stucco, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator shall submit:
1. Proof that the stove has been repaired and/or replace.
2. Pictures of backyard that show the discarded furniture and debris has been discarded.
3. Picture proof that the stucco has been repaired.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

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 2 resident beds did not have mattress pads, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator shall submit proof that mattress pads in room #1 have been placed on the beds.
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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/03/2024 01:49 PM - It Cannot Be Edited


Created By: Noemi Galarza On 05/03/2024 at 01:09 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 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: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) 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 (S2 & S3's) files show they have not received on-going training since at least 2019, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator shall submit proof that staff in-service training has been completed. Submit staff training logs that contain training topic and staff signatures.
Type B
Section Cited
CCR
80023(a)
Disaster & 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 that a Emergency Disaster Plan/Disaster and Mass Casualty Plan [LIC 610D] has not been developed in the most recent CCL form, and licensee is still using the 1 page old form, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator shall submit a copy of an updated Emergency Disaster Plan/Disaster and Mass Casualty Plan in the most recent CCL form [LIC 610D].
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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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