306002275-4-11-2023-22-AS-LMAZ-CQT6N8-20230411205707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002275
Report Date: 04/11/2023
Date Signed: 04/11/2023 08:57:55 PM

Document Has Been Signed on 04/11/2023 08:57 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ANGELS HOME		FACILITY NUMBER:	306002275
ADMINISTRATOR:	RAFAEL A. TORRES		FACILITY TYPE:	735
ADDRESS:	12061 LORALEEN STREET		TELEPHONE:	(714) 537-3413
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 6		CENSUS: 4	DATE:	04/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Marcelina Lived		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year Annual inspection. Upon arrival LPA was greeted by facility Staff Marcelina Lived and was granted entry. LPA began inspection with introduction and visit purpose. There are currently 4 Clients residing at the facility. One client and one staff were present during today's visit. Per Staff Lived, two clients were away with family and friend and one client was at Day Program. Client's arrived before LPA's visit ended LPA Martinez, along with Staff Lived conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following: Facility is a single-story house with four client bedrooms, two full and one half bathrooms, and one staff bedroom and an attached 2 car garage that is used for storage. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. The back yard has no shaded sitting area. There is a table and 4 chairs with an umbrella in the front lawn. Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. Hot water temperature in client bathroom was within regulatory requirements. Linen and hygiene supplies were stocked in hallway closet. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Emergency food and water supply is available. Smoke detectors are centrally wired and carbon monoxide detectors were found to be operational. Fire Extinguishers were charged and mounted and were last serviced on 06/13/2022. There is no record that facility is conducting Emergency Disaster/Fire Drills. Stove burners, microwave, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Laundry is done in the laundry room next to the kitchen area, and there is a locked cabinet in bathroom cabinet for storing laundry soap and other chemicals. Medications are centrally stored in a locked kitchen cabinet. Medications reviewed appear to have been dispensed accurately. (see LIC809C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME	FACILITY NUMBER: 306002275
	VISIT DATE: 04/11/2023

NARRATIVE

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First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility. The LIC610D, Emergency Disaster Plan is posted.

LPA reviewed three client files and one staff files. LPA interviewed 1 of 5 clients and 1 staff. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

Indoor and outside passageways are free of obstruction.

In order to update CCL file, please provide the following updated documents to CCL by 04/25/2023: 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610D); 4.) Surety Bond; and 5.) Administrator certificate.

Based on observations made during today's visit in the areas reviewed, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2023 08:57 PM - It Cannot Be Edited

Created By: Lydia Martinez On 04/11/2023 at 01:51 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME	FACILITY NUMBER: 306002275
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80023(d)

Disaster and Mass Casualty Plan-(d) Disaster drills shall be conducted at least every six months. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Licensee failed to ensure proof of disaster drills were maintained at the facility. There is no records of disaster drills being conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Licensee to conduct Fire Drills in accordance with CCR 80023. Licensee to keep record/log of all disaster drills. Licensee to submit proof to CCL by POC due date.

Type B

Section Cited

CCR

85087.2(b)

85087.2(b)Outdoor Activity Space (b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in there is no shaded area nor comfortable, and furnished for outdoor client use in the back yard. LPA observed a table and 4 chairs with an umbrella in the front lawn of the facility. Lawn is long and full of weeds. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2023
	Plan of Correction
1 2 3 4	LIcensee to read section cited. Will ensure the outdoor activity area will provide a comfortable, and furnished area for outdoor use for the clients by POC 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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Lydia Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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