198601751-9-15-2022-11-AS-JRAE-CJAT32-20220915142139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601751
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:22:31 PM

Document Has Been Signed on 09/15/2022 02:22 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ANGELIC CARE OF SOUTH BAY		FACILITY NUMBER:	198601751
ADMINISTRATOR:	JENNIFER SAN AGUSTIN		FACILITY TYPE:	740
ADDRESS:	2619 W. 231ST STREET		TELEPHONE:	(310) 539-2866
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY: 6		CENSUS: 6	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Sonel Midel House Mgr		TIME COMPLETED:	02:19 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Sonel Midel House Mgr. and the purpose of today’s visit was explained.

There are currently (6) residents in the facility. (0) residents are ambulatory, (6) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms, (3) full bathrooms, shaded back yard, front yard, laundry room and, attached 2 garage.

LPA and Sonel Midel House Mgr. toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-5 are occupied by residents and contain the mandated furniture. Bedroom 6 is a staff bedroom. Th bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is (114) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguishers are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair, However the exception is LPA observed eastside wall needs to be repaired during this inspection it is peeling of plaster and paint. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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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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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELIC CARE OF SOUTH BAY	FACILITY NUMBER: 198601751
	VISIT DATE: 09/15/2022

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private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & phone for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation noted on the 809D.

An exit interview was conducted with Sonel Midel House Mgr., a hard copy of the Report was provided as well as Appeal Rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/15/2022 02:22 PM - It Cannot Be Edited

Created By: Jeremiah Randle On 09/15/2022 at 02:04 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: ANGELIC CARE OF SOUTH BAY	FACILITY NUMBER: 198601751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) LPA observed eastside exterior wall needs to be repaired during this inspection it is peeling of plaster and paint., the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2022
	Plan of Correction
1 2 3 4	House Manager Administrator agreed to repair and conduct an in service training reagrding Maintenance and Operation with staff and complete repair within 7 days. Proof of correction will be submitted to CCLD on POC due date VIA photo to LPA's cell phone.

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Jeremiah Randle

LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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