306005742-3-29-2022-22-AS-PVEZ-CCYUHG-20220329153555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005742
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:36:04 PM

Document Has Been Signed on 03/29/2022 03:36 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 CARE GUEST HOME II		FACILITY NUMBER:	306005742
ADMINISTRATOR:	JABONERO, JANICE RACHELLE		FACILITY TYPE:	740
ADDRESS:	10222 MALINDA LN		TELEPHONE:	7142445885
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	6	CENSUS: 5	DATE:	03/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:46 AM
MET WITH:	Rubylyn Richardson - Secretary		TIME COMPLETED:	03:45 PM

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	Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Angels Care Guest Home II. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Fe Peneranda. Caregiver Nicasio Silva was also present. Rubylyn Richardson arrived later during the visit. The facility is licensed for 6 ambulatory residents. The facility has a Hospice waiver for 4 residents and there are currently 4 residents receiving Hospice services. There are currently 5 residents living in the facility. The last emergency disaster drill was conducted on January 28, 2022. LPA Velazquez observed the Complaint poster was not the correct size pursuant to regulation and advised both Caregivers to obtain the Complaint poster in the correct size of 20" x 26" and to prominently display it in the entry area. At 12:04 PM LPA Velazquez conducted a tour of the physical plant along with CG Peneranda. The 1 story home consists of 4 resident bedrooms with 3 bathrooms. The facility also has a living room, family room that includes a dining area, and kitchen. The 5 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails in the resident bedrooms. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 158.9 degrees Fahrenheit in the first bathroom, at 156.5 degrees Fahrenheit in the second bathroom, and at 160.8 degrees Fahrenheit in the third bathroom which was verified by CG Peneranda. LPA Velazquez immediately instructed both caregivers to lower the hot water temperature to prevent scalding any resident.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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: ANGELS CARE GUEST HOME II	FACILITY NUMBER: 306005742
	VISIT DATE: 03/29/2022

NARRATIVE

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LPA Velazquez inspected the kitchen along with CG Peneranda. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition. LPA Velazquez observed excessive grease stains inside of the oven. LPA also observed excessive grease stains on 5 pans which CG Peneranda verified. First Aid kit was checked and found to be missing tweezers. The facility did have a First Aid manual dated 2014 and LPA Velazquez advised the facility to obtain an updated First Aid manual.

LPA Velazquez along with CG Peneranda toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. LPA and CG observed 3 hospital beds leaning against a wall. LPA and CG also observed a rusty walker, a mattress, and a piece of wood in the back yard. LPA advised the back yard should be free of debris and any broken/used furniture. LPA and CG observed the exit gate did not have a self-closing latch which CG Peneranda verified. There were no security bars or weapons on the premises.

No staff files were reviewed at the time of this visit. LPA Velazquez briefly reviewed resident physician reports that indicated a non-ambulatory or bedridden status. LPA Velazquez requested copies of resident physician reports as well as hospice documentation as the facility is not licensed for non-ambulatory or bedridden residents. Some of the resident records also indicated some residents require maximum assist with all Activities of Daily Living (ADLs). LPA Velazquez indicated a written physician's order indicating the need for the bed rails should be present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports which LPA reviewed with Ms. Richardson.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An immediate civil penalty was also issued. An exit interview was conducted with Rubalyn Richardson and a copy of this report along with the appeal rights, and a copy of the LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/29/2022 03:36 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 CARE GUEST HOME II	FACILITY NUMBER: 306005742
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(1-2)

87202(a)(1-2) Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city and countyfire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the follwoing types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services or the State Fire Marshal. (1) Non-ambulatory persons (2) Bedridden persons.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 of 5 cases as there are residents that are listed as non-ambulatory or bedridden on their physician's reports or are diagnosed with Dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/30/2022
	Plan of Correction
1 2 3 4	Licensee to obtain a new Fire Clearance pursuant to statute and regulation and submit written proof to LPA by POC due date. Civil penalty also issued.

Type A

Section Cited

CCR

87608(a)(3)

87608(a)(3) Postural Supports. Based on the individual's preadmission appraisal, and subsequent changes to the appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the follwoing conditions. (3) A written order from a physician indicating the need for the postural support shall be mainttained in the resident's record. The licensing agency shall be authorized to require additional documentation to verify the order.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 4 out of 5 cases where residents had bed rails without a written physician order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/30/2022
	Plan of Correction
1 2 3 4	Licensee to ensure there is a written physician order indicating the need for the bed rails in each resident file and submit written proof to LPA by POC due 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/29/2022 03:36 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 CARE GUEST HOME II	FACILITY NUMBER: 306005742
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 3 out of 3 bathrooms which poses an immediate health, safety or personal rights risk to persons in care. The hot temperature was measured at a range of 156.5 degrees F to 160.8 degrees F.
	POC Due Date: 03/30/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the hot water temperature is maintained pursuant to regulation and submit written 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 03/29/2022 03:36 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 CARE GUEST HOME II	FACILITY NUMBER: 306005742
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

87705(h) Care of Persons with Dementia. (h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of the residents.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 gates which poses/posed a potential health, safety or personal rights risk to persons in care. The gate in the backyard did not have a self-closing latch.
	POC Due Date: 03/30/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the exit gates are self-closing and submit written 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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