306003459-7-1-2024-22-AS-SHAD-D6RN24-20240701100406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003459
Report Date: 07/01/2024
Date Signed: 07/01/2024 10:04:19 AM

Document Has Been Signed on 07/01/2024 10:04 AM - 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:	GOLDEN ANGEL OF LA HABRA		FACILITY NUMBER:	306003459
ADMINISTRATOR:	LORNITA S. PANIS		FACILITY TYPE:	740
ADDRESS:	1141 CHERI DRIVE		TELEPHONE:	(562) 694-0741
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 3	DATE:	07/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:35 AM
MET WITH:	Lornita S. Panis		TIME COMPLETED:	10:15 AM

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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Lornita S. Panis and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 8:30AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with detached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 3 residents present at the facility. Resident Bedrooms: the 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 115 degrees F in both bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 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. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the laundry room, after corrections. Toxins: observed locked in the garage and laundry room, after corrections. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:15AM, LPA reviewed 3 resident files and 2 staff files, interviewed 3 residents and 2 staff, and inspected medications for 3 residents. Facility does not handle resident money. CONTINUED

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024

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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Document Has Been Signed on 07/01/2024 10:04 AM - 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
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: 07/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure toxins were secured in the non-lockable garage, knives were secured in the non-lockable cabinet under the kitchen sink, and Tylenol was secured in the kitchen cabinet, which poses an immediate safety risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	During the inspection, the licensee secured these items and LPA confirmed. Licensee stated they will train staff on ensuring dangerous items are secured and will submit proof to LPA by POC due date.

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/01/2024 10:04 AM - 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
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: 07/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(1)

Incidental Medical and Dental Care Services

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure the medications of 3 out of 3 residents were tracked by not using a Medication Administration Record (MAR), which poses a potential health risk to persons in care.
	POC Due Date: 07/29/2024
	Plan of Correction
1 2 3 4	Licensee stated they will immediately start using a MAR for each resident and will submit proof to LPA by POC due date.

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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
	VISIT DATE: 07/01/2024

NARRATIVE

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During the inspection, LPA and AD observed the following: based on observation, the licensee did not ensure toxins were secured in the non-lockable garage, knives were secured in the non-lockable cabinet under the kitchen sink, and Tylenol was secured in the kitchen cabinet; based on documents, the licensee did not ensure the medications of 3 out of 3 residents were tracked by not using a Medication Administration Record (MAR).

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024

LIC809 (FAS) - (06/04)

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