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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603591
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:46:54 PM


Document Has Been Signed on 09/26/2023 03:46 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:TOUCH OF AN ANGELFACILITY NUMBER:
198603591
ADMINISTRATOR:THOMAS, STACEYFACILITY TYPE:
740
ADDRESS:836 E 74TH STREETTELEPHONE:
(323) 879-5408
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY:6CENSUS: 6DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Stacy Thomas - Administrator TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Stacey Thomas the administrator of the facility and was granted access. There are six (6) residents who reside within the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. Administrator advised she will send a completed Infection Control Plan within 7 days.


Physical Plant/Environment Safety:

· The facility is a single-story house located in a residential neighborhood. It is licensed for a capacity of six (6) residents, five (5) of which may be non-ambulatory and they also have a hospice waiver for two (2), and an approval for one (1) bedridden residnets. It has four (4) client rooms, a dining room, a kitchen, a shared restroom (R1) which had a hot water temperature reading of 109.7 Degrees F which also held the facility's washing and drying machines, and a front and back yard 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. The facility has one (1) fully charged fire extinguisher located near the kitchen of the facility.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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Document Has Been Signed on 09/26/2023 03:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: TOUCH OF AN ANGEL
FACILITY NUMBER: 198603591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 4 out of 6 residents as they did not have a Appraisal/Needs and Service Plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Administrator is to ensure that all residents will have Appraisal/Needs and Service Plan in their records. Administrator is to email LPA the appraisals for the 4 residents that do not have one by the POC due date.
Type B
Section Cited
CCR
87506(b)(14)
(b) Each resident's record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.

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 6 out of 6 residents, as there were no physician's orders for the month of september on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator is to ensure that physician's orders for the resident's medications are kept on file at all times. Administrator will obtain the physician's orders for the resident's medications for the month of September and email LPA proof of the physician's orders being on file.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2023 03:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: TOUCH OF AN ANGEL
FACILITY NUMBER: 198603591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

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 6 out 6 residents, as the Complaint Poster for RCFEs was not publicly displayed in the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Administrator will make sure that the PUB 475 posted is displayed in a prominent and public location within the facility. Administrator is to send LPA photographic proof that it has been posted in the facility by the POC due date.

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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 09/26/2023 03:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: TOUCH OF AN ANGEL
FACILITY NUMBER: 198603591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 6 out of 6 residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Administrator is to ensure that the facility has a 2-day supply of perishable and 7-day supply of non-perishable food for the residents. Administrator is to show LPA photographic proof that she has the appropriate ammount of perishable and non-perishable food by the 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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TOUCH OF AN ANGEL
FACILITY NUMBER: 198603591
VISIT DATE: 09/26/2023
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· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for six (6) residents, five (5) of which can be non-ambulatory, two (2) hospice waivers are approved, along with one (1) bedridden resident.


· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of four (4) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Four (4) staff files were reviewed for criminal background clearance and training.


· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Resident Rights/Information:

· Physician orders were not found within the Resident files.

Resident Records/Incident Reports:

· Six (6) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed, and four (4) of them did not have an Appraisal/Needs and Service Plan on file, and none of them had physician's orders for their medications.


Food Service:

· The kitchen was inspected and did not have a 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.



· No restricted Health Care plan required for the clients in the facility.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TOUCH OF AN ANGEL
FACILITY NUMBER: 198603591
VISIT DATE: 09/26/2023
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Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

LPA was not able to complete the annual inspection at this time, and will be returning to complete the review of medications, along with staff and resident interviews.


Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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