374604028-5-17-2024-08-AS-RFUN-D5CTWV-20240517150611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604028
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:06:22 PM

Document Has Been Signed on 05/17/2024 03:06 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ANGEL'S HOME CARE LLC		FACILITY NUMBER:	374604028
ADMINISTRATOR:	SOUMOUNTHA, KATHY		FACILITY TYPE:	740
ADDRESS:	427 CABO COURT		TELEPHONE:	(760) 453-2488
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92058
CAPACITY:	6	CENSUS: 3	DATE:	05/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mary Cuaresma		TIME COMPLETED:	03:15 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 (LPAs) Ryan Fulton and Carmen Lopez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to caregiver Mary Cuaresma. The facility's license shows a maximum capacity of six (6) residents, of which four (4) may be non-ambulatory and one (1) may be bedridden. During today’s inspection there were three (3) clients in care. LPAs and Mary Cuaresma, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all of which are safely stored. Cooking/dining equipment and utensils were present. Toxic chemicals/poisons were locked and inaccessible accessible to residents. Medications were labeled, as required, and stored in locked areas. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 115.2 F, bathroom #1 sink was 113.2 F and bathroom #2 sink was 117.3 F. No pools or bodies of water exist on the premises. Per caregiver, no firearms or ammunition are kept at the facility. Carbon monoxide/Smoke detectors, emergency lighting, and facility. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. (Continuation on LIC809-C)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -76-2311
LICENSING EVALUATOR NAME: Ryan Fulton	TELEPHONE: 619-629-8938
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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 05/17/2024 03:06 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGEL'S HOME CARE LLC	FACILITY NUMBER: 374604028
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87311

Telephones

All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on oservations, the licensee did not comply with the section cited above. In one out of 3 residents did not have access to a phone on the facility premises which poses a personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Licesee will contact the phone company, and will continue phone services.

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 the pysicians report was five years out of date in one out of Three residents in care poses a potential health, and safety risk to person in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Licensee will contact residents provider to Schedule an appointment By POC due date. 05/31/24 once physicians report has been updated licensee will submit a copy of LIC602 to the LPA.

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: Jennifer Lott	TELEPHONE: (619) -76-2311
LICENSING EVALUATOR NAME: Ryan Fulton	TELEPHONE: 619-629-8938
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGEL'S HOME CARE LLC	FACILITY NUMBER: 374604028
	VISIT DATE: 05/17/2024

NARRATIVE

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(Continuation of LIC809)

Deficiencies were sited during today’s annual inspection and can be found on the LIC809-D pages of this report. Technical Violations (TV) were provided at today’s inspection.

An exit interview was conducted with Caregiver Mary Cuaresma to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. The signature below confirms the documents were received.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -76-2311
LICENSING EVALUATOR NAME: Ryan Fulton	TELEPHONE: 619-629-8938
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

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