565801215-3-3-2022-29-AS-TCAA-CC6MCE-20220303082922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801215
Report Date: 03/01/2022
Date Signed: 03/03/2022 08:29:55 AM

Document Has Been Signed on 03/03/2022 08:29 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANGELS II		FACILITY NUMBER:	565801215
ADMINISTRATOR:	JOANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	2375 MCDONALD COURT		TELEPHONE:	(805) 404-5201
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 5	DATE:	03/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	Joann Trupiano		TIME COMPLETED:	03:48 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 02:09 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensee Joann Trupiano and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was last serviced 04/27/2021.

KITCHEN: Knives were found in an unlocked drawer. Other knives and cleaning supplies are stored in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All medications were stored in a locked armoire. BEDROOMS: The LPA observed two single-occupancy resident bedrooms and two shared bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean and sanitary and in operating condition. Cleaning items are stored in locked cabinets. COMMON SPACES: The living room, family room and dining room furniture were observed to be in good condition. The patio is equipped with furniture for resident use. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Infection control postings were observed. The facility had an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Today's reports and appeal rights were discussed and issued by email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

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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Document Has Been Signed on 03/03/2022 08:29 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGELS II	FACILITY NUMBER: 565801215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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. LPA observed knives stored in an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2022
	Plan of Correction
1 2 3 4	Staff secured the knives and scissors in a locked drawer. Administrator will provide evidence of training staff on securing dangerous items to CCL on or before 03/07/22.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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