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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003459
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:30:51 PM

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:GOLDEN ANGEL OF LA HABRAFACILITY NUMBER:
306003459
ADMINISTRATOR:LORNITA S. PANISFACILITY TYPE:
740
ADDRESS:1141 CHERI DRIVETELEPHONE:
(562) 694-0741
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 6DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Lornita S. PanisTIME COMPLETED:
02:45 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Lornita S. Panis and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen and observed the following: LPA and AD observed there were 2 staff present. LPA observed 6 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen, and observed they were clean and organized. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

During the inspection, LPA and AD observed the following: in the non-lockable living room closet, medications accessible to residents; in the kitchen, medications, knives, and scissors accessible to residents in unlocked (but lockable) storage areas and non-lockable drawer; and in the laundry room, toxins accessible to residents in unlocked (but lockable) storage areas. During the inspection, AD properly secured all of these items and LPA confirmed. LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA provided technical assistance regarding resident records, staff records, outings, and visitation. LPA requested and reviewed resident roster, staff roster, staff files, resident files, emergency plan, and COVID-19 mitigation plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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: GOLDEN ANGEL OF LA HABRA
FACILITY NUMBER: 306003459
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation: (a) The facility shall be clean, safe.... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure toxins, medications, sharps, and other dangerous items were inaccessible to residents in the living room, kitchen, and laundry room, which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/30/2021
Plan of Correction
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Licensee immediately secured the toxins, medications, sharps, and other dangerous items during today's inspection and LPA confirmed.
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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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