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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004079
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:05:18 PM


Document Has Been Signed on 06/22/2022 04:05 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:ANGELA'S RESIDENTIAL CAREFACILITY NUMBER:
306004079
ADMINISTRATOR:ANGELA TALPOS O'CONNORFACILITY TYPE:
740
ADDRESS:3141 BRAY LANETELEPHONE:
(949) 326-8797
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 5DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Angela Talpos O'ConnorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 2:59 pm, LPA was greeted and granted entry by Caregiver Martha Higuera followed by the Administrator (Admin) Angela Talpos O'Connor after completing the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperature for all visitors on a sign in sheet. LPA observed the required COVID-19 precautionary sign posted on the door of the main entrance. The PUB475 See Something, Say Something poster was observed on the kitchen wall by the refrigerator in the size of 8.5"x11." The Administrator's Certificate expires on 12/17/2023.

At 3:05 pm, LPA toured the interior and exterior portions of the facility with the Admin. The facility is a single level structure and licensed for six non-ambulatory residents of which one may be bedridden; and has a hospice waiver for five. Currently, there a total of five residents in the facility of which two are in hospice care. Facility appeared clean and sanitary in all areas observed. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxides, and auditory exit alarms tested operational. The restrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water measured at 105.9 degrees Fahrenheit in Restroom #1; 106.3 degrees Fahrenheit in Restroom #2; and 110.8 degrees Fahrenheit in Restroom #3. LPA observed hand washing signs, paper towels, and hand soaps in all three restrooms. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. The fire extinguisher was charged and mounted in the kitchen. For the exterior portion, LPA observed patio furniture under a lattice, and the grounds were free of tripping hazards. The side gate was self-closing and self-latching.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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: ANGELA'S RESIDENTIAL CARE
FACILITY NUMBER: 306004079
VISIT DATE: 06/22/2022
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LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility had back-up emergency food and water supply stored in the garage and a bin outside. The First Aid Kit had all the required components, and the facility had sufficient PPEs and incontinence supplies stored in the garage.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Residents have access to the facility iPad upon request.



LPA consulted the following: To enlarge the PUB475 See Something, Say Something poster in the size of 20"x26."

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the correction. An exit interview was conducted with Administrator Angela Talpos O'Connor, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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