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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003809
Report Date: 08/02/2024
Date Signed: 08/02/2024 12:23:56 PM


Document Has Been Signed on 08/02/2024 12:23 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 LLCFACILITY NUMBER:
306003809
ADMINISTRATOR:ROBERT LEALFACILITY TYPE:
740
ADDRESS:9781 OMA PLACETELEPHONE:
(714) 530-7143
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
08/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Mary Lou LealTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20240726162500. LPA met with Licensee Mary Lou Leal and explained the purpose of the inspection.

During the course of the investigation, deficiencies were observed. During interviews, Resident 1 (R1) stated they fell yesterday in the front courtyard. Per R1, they requested staff help them carry two bags, but staff declined, and as they attempted to walk out the front door of the facility with the two bags, they fell. LPA observed R1 had a swollen thumb with discoloration and had a leg boot brace. R1 provided LPA with pictures of their knee with blood, and blood running down their leg. Per R1, Licensee stated she would take them to the emergency room but stated she did not have time yesterday.

During their interview, Licensee confirmed R1 had fallen yesterday and sustained the injury on their thumb and knee. LPA inquired why medical attention was not sought, and Licensee stated she did not have time to take R1 yesterday and would not have time to take them today.

Based on observations made during this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalty is also being assessed. See the attached LIC421IM. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
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 08/02/2024 12:23 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ANGELS HOME LLC
FACILITY NUMBER: 306003809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2024
Section Cited
CCR
87468.1

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services.

This requirement is not met as evidence by:
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Licensee immediately called 911, and emergency services arrived to transport R1 to hospital. Licensee stated they will conduct staff training regarding resident personal rights immediately and a copy provided to LPA via email by POC.
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Based on Licensee admission, they did not provided medical care to R1, after they sustained a fall resulting in an injury, which poses an immediate health and safety risk to persons in care.
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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