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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005151
Report Date:
07/27/2023
Date Signed:
07/27/2023 04:22:24 PM
Document Has Been Signed on
07/27/2023 04:22 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:
ANGIE'S HOME
FACILITY NUMBER:
306005151
ADMINISTRATOR:
HO, DUNG VAN
FACILITY TYPE:
735
ADDRESS:
1401 S JEFFERSON AVE
TELEPHONE:
(714) 733-9552
CITY:
FULLERTON
STATE:
CA
ZIP CODE:
92832
CAPACITY:
6
CENSUS:
4
DATE:
07/27/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:00 PM
MET WITH:
Kendrick Ho
TIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by a client due to staff being asleep. LPA knocked on the staff bedroom door several times before receiving a response. Staff Kendrick Ho answered the door and stated they had been sleeping. LPA discussed the purpose of the inspection and began inquiring about the clients present and their care needs. Staff Ho was unable to answer LPA questions and contacted Administrator (AD) Don Ho by phone. AD stated they were at the Social Security office, and they had been waiting for an extensive period of time. LPA informed them staff currently present was unable to answer LPA’s questions. AD arrived at 12:30 p.m. and stated staff is ”new” and they “don’t know”; a Deficiency was cited on today’s date.
During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:
This is a one-story house with four client bedrooms, two bathrooms, and one staff bedroom. All client bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed one staff and four clients present. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 132.2 F degrees; a Deficiency was cited on today’s date.
Upon request a facility register of clients was not available; a Deficiency was cited on this date. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the living area and at the entrance of the facility. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. (Cont. LIC809-C)
SUPERVISORS NAME
:
Armando J Lucero
LICENSING EVALUATOR NAME
:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
8
Document Has Been Signed on
07/27/2023 04:22 PM
- It Cannot Be Edited
Created By:
Claudia Gutierrez
On
07/27/2023
at
02:36 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ANGIE'S HOME
FACILITY NUMBER:
306005151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(a)(3)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (3) All staff who are assigned to assist clients with the self-administration of injectable medication shall observe the following procedures: (B) A syringe and needle shall only be used once per injection on one resident and then properly disposed of in accordance with the California Code of Regulations, Title 8, Section 5193.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and AD admission, the licensee did not comply with the section cited above as insulin dependent client is not assisted with injectable medication and client themselves disposes of needle in a common trash bin located in the kitchen, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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AD stated they would ensure client is assisted with self-administration of injectable medication and sharps container would be obtained to dispose of used needles. An in-service will be completed for all staff to ensure staff is able to assist client and needles are disposed of in sharps container. Sign-in log for in-service will be provided to LPA via email by POC date.
Type A
Section Cited
CCR
85095.5(a)(6)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (6) All direct care staff assigned to assist clients with the self-administration of medication or assigned to the care of a client shall clean and disinfect reusable medical equipment as follows:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and AD admission, the licensee did not comply with the section cited above as diabetes testing equipement for insulin dependent client is kept in an unlocked kitchen cabinet and client manages equipment themselves, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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AD immediately made diabetes testing equipment inaccessible and stated they will observe client when testing and reusable equipment would be immediately disinfected by staff. An in-service will be completed for all staff to ensure equipment is disinfected after every use. Dated sign-in sheet will be provided to LPA via email by POC date.
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
LICENSING EVALUATOR NAME:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
07/27/2023 04:22 PM
- It Cannot Be Edited
Created By:
Claudia Gutierrez
On
07/27/2023
at
02:36 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ANGIE'S HOME
FACILITY NUMBER:
306005151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview and AD admission, the licensee did not comply with the section cited above as facility staff present during LPA's arrival was sleeping and was unable to answer LPA's questions pertaining to care of the clients. Per AD, staff is new and "doesn't know," which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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AD will provide staff training to ensure they are competent to provide the services necessary to meet individual client needs. Certificate for completed trainings and dated in-service sign-in sheets will be provided to LPA via email by POC date.
Type A
Section Cited
CCR
85068.2(b)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and AD admission, the licensee did not comply with the section cited above in two out of four client files, as they do not contain a written Needs and Services Plan, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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AD stated a written Needs and Serivces Plan would be obtained prior to admission for all future admissions. AD to complete Needs and Services for all current facility clients. AD to provide LPA with Needs and Serivces Plans for each facility client by POC via email.
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
LICENSING EVALUATOR NAME:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
07/27/2023 04:22 PM
- It Cannot Be Edited
Created By:
Claudia Gutierrez
On
07/27/2023
at
02:36 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ANGIE'S HOME
FACILITY NUMBER:
306005151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80092(b)(5)
Restricted Health Conditions
(b) Care for the following health conditions must be provided only as specified in Sections 80092.1 through 80092.11. (5) Insulin-dependent Diabetes as specified in Section 80092.8.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, staff and client interview, the licensee did not comply with the section cited above as a client with a restricted health condition was retained and staff is not assisting client, is unaware of what equipment is required for the condition or where equipment should be stored, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
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AD stated they would submit an exception to Community Care Licensing by POC date. AD stated an in-service will be held to ensure client is assisted with self-injectable medication by staff. Dated in-service sign-in sheet will be provided to LPA via email by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
07/27/2023 04:22 PM
- It Cannot Be Edited
Created By:
Claudia Gutierrez
On
07/27/2023
at
02:36 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ANGIE'S HOME
FACILITY NUMBER:
306005151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as potential tripping hazards including above ground wood dividers and white tubes were observed in the backyard which poses a potential safety risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
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AD stated they would remove wood dividers and white tubes from the backyard and provide LPA with picture proof via email by POC date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on water temperature testing, the licensee did not comply with the section cited above in two out of two faucets, which tested at 132.2 degrees F, which poses a potential safety risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
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AD stated they would monitor water temperature to ensure it is maintained within regulation. AD will provide LPA with water temperature log of water temperature monitoring via email by POC date.
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
LICENSING EVALUATOR NAME:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
07/27/2023 04:22 PM
- It Cannot Be Edited
Created By:
Claudia Gutierrez
On
07/27/2023
at
02:36 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ANGIE'S HOME
FACILITY NUMBER:
306005151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(d)(1)
Client Medical Assessments
(d) In addition to Section 80069(c), the medical assessment for clients in ARFs shall include the following: (1) A physical examination of the person, indicating the physician's primary diagnosis and secondary diagnosis, if any.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as two out of two client physician reports do not include information pertaining to diagnosis and four out of four physician's report have at least one blank page, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
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2
3
4
AD stated they would obtain a completed physician report for all facility clients and provide LPA with a copy via email by POC date.
Type B
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as two out of four client physician reports do not contain information pertaining to ambulatory status which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
1
2
3
4
AD stated they would obtain a completed physician report for all facility clients and provide LPA with a copy via email by POC date.
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
LICENSING EVALUATOR NAME:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
07/27/2023 04:22 PM
- It Cannot Be Edited
Created By:
Claudia Gutierrez
On
07/27/2023
at
02:36 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
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
ANGIE'S HOME
FACILITY NUMBER:
306005151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/27/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80071(a)(1)
Register of Clients
(1) The licensee shall maintain in the facility a register of all clients. The register shall be immediately available to, and copied for, licensing staff upon request, and must contain current information on the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as a facility register of all clients was not available upon request, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date:
08/28/2023
Plan of Correction
1
2
3
4
AD stated they would complete and maintain a register of all facility clients at all times and provide LPA with a copy via email by POC 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
LICENSING EVALUATOR NAME:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
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:
ANGIE'S HOME
FACILITY NUMBER:
306005151
VISIT DATE:
07/27/2023
NARRATIVE
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Fire extinguisher was observed to be fully charged. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication was observed to be locked and lock is operational. Needles and diabetes testing supplies were observed to be kept in an unlocked kitchen drawer; a Deficiency was cited on today’s date. AD stated they allow client to manage their own insulin and testing equipment because they do not want to come in contact with client’s blood, client then disposes of used needles in a common use trash can located in the kitchen; a Deficiency was cited on today’s date. LPA reviewed four client files and two staff files. LPA interviewed three clients and one staff.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Armando J Lucero
LICENSING EVALUATOR NAME
:
Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
LIC809
(FAS) - (06/04)
Page:
8
of
8