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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004383
Report Date: 08/23/2024
Date Signed: 08/23/2024 04:07:34 PM

Document Has Been Signed on 08/23/2024 04:07 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAN ANGELO HOMEFACILITY NUMBER:
306004383
ADMINISTRATOR/
DIRECTOR:		RIVAS, YANIRAFACILITY TYPE:
735
ADDRESS:16323 LAMBERT ROADTELEPHONE:
(562) 902-8429
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 6CENSUS: 6DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:48 AM
MET WITH:Administrator Yanira RivasTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tyler Reyes conducted an a site visit for the annual inspection. Upon arriving at the facility, LPA met with Yanira Rivas (Administrator) and explained the purpose of the visit.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, attached garage/office/laundry, dining area, kitchen, 4 bedrooms and 2 bathrooms.

LPA Reyes used the inspection tool, and toured the facility inside and out, reviewed food supply, reviewed (6) resident and (5) staff files, and reviewed (6) resident medications. LPA Reyes observed from reviewing the San Angelo Facility Staff Schedule August 2024 along with Facility Personnel Report Summary Dated 8/22/24 that S1 was not cleared and associated to facility. Administrator Yanira states S1's first day was on 8/18/24 and worked on 8/23/24. S1 states with Administrator Yanira present in the room they have worked a total (5) days at the facility 8/16/24-8/18/24 and 8/22/24-8/23/24. Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. . The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors/carbon monoxide detectors located throughout the facility, tested and operating. Knives and toxins are in locked cabinets, and inaccessible to residents. There is a sufficient amount of perishable and non perishable food supply. Medications reviewed, and appear to be given as prescribed. Administrator's certificate expires on 11/9/24. The facility held a fire drill on 11/9/24.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 08/23/2024 04:07 PM - It Cannot Be Edited


Created By: Tyler Reyes On 08/23/2024 at 03:11 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN ANGELO HOME
FACILITY NUMBER: 306004383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review of the San Angelo Facility Staff Schedule August 2024 along with Facility Personnel Report Summary Dated 8/22/24 that S1 was not cleared and associated to facility. Administrator Yanira states S1's first day was on 8/18/24 and worked on 8/23/24. S1 states with Administrator Yanira present in the room they have worked a total (5) days at the facility 8/16/24-8/18/24 and 8/22/24-8/23/24.


which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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LPA advised Administrator that S1 cannot be present and/or working at the facility until criminal record clearance has been received and S1 has been associated to the facility. Administrator to submit Criminal Record Clearance by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAN ANGELO HOME
FACILITY NUMBER: 306004383
VISIT DATE: 08/23/2024
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Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809D for details. An exit interview was conducted. This report and appeal rights were discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

Immediate $500.00 Civil Penalty was issued.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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