<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006228
Report Date: 01/24/2025
Date Signed: 01/24/2025 02:43:03 PM

Document Has Been Signed on 01/24/2025 02:43 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGEL COMFORT CARE 2FACILITY NUMBER:
306006228
ADMINISTRATOR/
DIRECTOR:		TEVES, ANGELINAFACILITY TYPE:
740
ADDRESS:1212 W ROWAN STTELEPHONE:
(562) 936-8063
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:07 AM
MET WITH:Asteria OriasTIME VISIT/
INSPECTION 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 Analysts (LPA) Samer Haddadin made an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted by Staff (S1) Ricky Edora and granted entry into the facility. S1 contacted administrator (AD), Angelina Teves, via phone and LPA spoke with AD and explained the nature of the visit. AD joined the visit at 8:33 AM. Prior to the start of the tour, LPA observed a small plastic cup that had 4 prescription pills on the dining table and in plain view. LPA also observed one ambulatory resident sitting at the same table. I asked the caregiver if the medication belonged to the resident sitting at the table, he said no and that it had belonged to a different resident and forgotten it on the table for unknown period of time. Medication was removed and given to the resident it belonged to.

LPA toured the interior and exterior of the facility and observed the following:
The facility is a one-story home with five resident bedrooms, three bathrooms, living room, kitchen, staff bedroom, and an attached two car garage.
LPA observed Residents’ bedrooms had the required furniture, bed linens and closet/drawer as well as space to accommodate each resident comfortably. LPA observed a camera for each resident’s room placed facing the resident’s bed. AD did not have permission from the resident and was advised that this was a violation of personal rights . AD removed all cameras from all resident’s bedrooms. Toilets and water faucets were observed to be operational, grab bars were secure, and shower was free of mold/mildew. Water temperature was tested in all three restrooms and measured between 111.2 and 112.3 Degree Fahrenheit.

LPAs observed smoke detectors/carbon monoxide in common areas, hallways, and bedrooms; all were tested operational. Fire extinguisher was fully charged with service tag indicating last inspection date was on February 16th, 2024. However, Fire drills are not being conducted quarterly; nor did AD have any record of last drill.

LPA checked the kitchen area, and all appliances were tested operational. LPA observed sharps and knives where locked and secured, however, (***CONTINUE 809C**)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGEL COMFORT CARE 2
FACILITY NUMBER: 306006228
VISIT DATE: 01/24/2025
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
26
27
28
29
30
31
32
LPA checked under the kitchen sink and observed chemicals and cleaning supplies to be unsecured due to a broken lock. LPA advised AD of the issue and all chemicals and cleaning supplies were later secured in a locked cabinet located in the garage. LPA also observed a broken lock for a cabinet located in the garage that has cleaning supplies. LPA observed AD placing all chemicals and cleaning solution in another secured cabinet

LPAs toured the exterior of the facility and observed there was a shaded seating area and ample space for activities; all outside emergency exists were free of tripping hazards and or obstructions or barriers. Facility had inground pool and that is fully fenced with a gate that swings away from pool and is self-latching. LPA observed 3 gallons of paint on the east side of the building alongside of 32oz lighter fluid container that did not have a cap on nor secured. The container was full.

LPA observed the facility does not have 7-day supply of non-perishable foods nor any emergency water. LPA checked First aid kit and observed it had all the required elements including bandages, tweezers, thermometer, and scissors however, it did not have manual. LPA reviewed 5 residents’ files and observed all files had all required documentation. LPA reviewed all resident's medication and observed that AD does not keep any daily record of the medication prescribed by physician. Last recorded date on medication was November 21, 2024. LPA asked AD how medication is being administered, AD advised that the person who is in charge of medication had taken the day off and usually pre-fills all resident's medication using containers to help caregiver administer meds Current caregivers. LPA asked caregivers if they had any training in regards of Meds, they both said no. LPA could not verify any medical records for any of the five residents in care.


LPAs also reviewed 2 staff files and observed that none of the current staff had any training in dementia care nor any documented training per regulation

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 and appeal rights were provided to AD at end of inspection.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/24/2025 02:43 PM - It Cannot Be Edited


Created By: Samer Haddadin On 01/24/2025 at 01:23 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: ANGEL COMFORT CARE 2
FACILITY NUMBER: 306006228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
...To be accorded dignity in their personal relationships with staff, residents, and other persons.
Based on observation the licensee did not comply with the section cited above in having cameras in all five resident's rooms to monitor without permission which poses an immediate personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
1
2
3
4
AD removied all cameras. AD will conduct training for all staff and submit proof to LPA by E mail 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 01/24/2025 02:43 PM - It Cannot Be Edited


Created By: Samer Haddadin On 01/24/2025 at 01:43 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: ANGEL COMFORT CARE 2
FACILITY NUMBER: 306006228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above by having a broken lock on cabenit that secures chemicals which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
1
2
3
4
AD secured and locked chemicals, and . AD will conduct training for all staff and submit proof to LPA by E mail by POC Due Date
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review the licensee did not comply with the section cited above in not maintaining any medication records for all five residents in care which poses an immediate health, safety risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
1
2
3
4
. AD will conduct training for all staff and submit proof to LPA by E mail 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/24/2025 02:43 PM - It Cannot Be Edited


Created By: Samer Haddadin On 01/24/2025 at 01:43 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: ANGEL COMFORT CARE 2
FACILITY NUMBER: 306006228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in leavining medication in plain view and accessible to residents in care which poses an immediate health, safety risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
1
2
3
4
Care giver gave the medication to resident, and . AD will conduct training for all staff and submit proof to LPA by E mail by POC Due Date
Type A
Section Cited
CCR
87705(b)(1)(A)
Care of Persons with Dementia
(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (A) Dementia care, including, but not limited to, knowledge about hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation record review, the licensee did not comply with the section cited above in not maintaining and training for staff in regards to medication or dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
1
2
3
4
. AD will conduct training for all staff and submit proof to LPA by E mail 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/24/2025 02:43 PM - It Cannot Be Edited


Created By: Samer Haddadin On 01/24/2025 at 01:43 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: ANGEL COMFORT CARE 2
FACILITY NUMBER: 306006228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above as AD did not have the minimum of one week of perishable nor emergency water which poses potential health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
1
2
3
4
AD will maintain a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises and will send proof to LPA by e mail by POC due date
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in storing resident's medication in seperate containiner which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
1
2
3
4
. AD will conduct training for all staff and submit proof to LPA by E mail 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/24/2025 02:43 PM - It Cannot Be Edited


Created By: Samer Haddadin On 01/24/2025 at 01:43 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: ANGEL COMFORT CARE 2
FACILITY NUMBER: 306006228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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 in failing to maintain record for medication dosage for any of the resident's which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
1
2
3
4
. AD will conduct training for all staff and submit proof to LPA by E mail by POC Due Date
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 in not havining any emergency drills done ever since since licensed which poses a potential health, safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
1
2
3
4
. AD will conduct training for all staff and submit proof to LPA by E mail 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8