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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801215
Report Date: 03/21/2024
Date Signed: 03/21/2024 06:47:20 PM


Document Has Been Signed on 03/21/2024 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ANGELS IIFACILITY NUMBER:
565801215
ADMINISTRATOR:JOANN TRUPIANOFACILITY TYPE:
740
ADDRESS:2375 MCDONALD COURTTELEPHONE:
(805) 404-5201
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Honorata Perla AvestroTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff Honorata Perla Avestro and Magdalena Guansing. LPA explained the reason for the visit. Staff contacted Licensee JoAnn Trupiano. LPA spoke with Mrs. Trupiano who stated that she is not feeling well therefore, unable to meet LPA at the facility today. Mrs. Trupiano stated that staff can review and sign the report on her behalf.

At approximately 10:40am, LPA and staff 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 04/12/2023. 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. At approximately (approx) 10:45 a bottle of Tylenol on the kitchen table. BEDROOMS: The LPA observed four (4) bedrooms two single-occupancy resident bedrooms and two shared bedrooms which were furnished with appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms observed clean and sanitary and in operating condition. Cleaning items are stored in locked cabinets. At approx. 10:30am, LPA observed medications belonging to staff accessible to others in an unlocked cabinet in the hallway. 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. No bodies of water.

Resident records reviewed at approx. 11:15am - Resident files were reviewed for updated Needs and Services plans, medical assessments, admission agreements, and all other pertinent documents in their files. Administrator did not have a current Needs and services plan for resident #3.

(Continue to LIC809C).

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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 03/21/2024 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. Bottle of tylenol observed on kitchen table accessible to others. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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Staff locked the tylenol bottle in the cabinet during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled.

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. LPA observed living area and resident room walls window coverings with dust and stains. This poses a potential health, safety or personal rights risk to persons in care. Resident #1's room was observed with dirty napkins on the floor; urine stains on the bedding.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall develop a plan to ensure that the facility is maintained clean and sanitary at all times. Provide cleaning schedule as proof to ensure facility is maintained clean at all times.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) staff files reviewed lacked required annual training. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall ensure all staff receive the required annual training by POC date. Submit proof of training according to training requirements by POC due date 3/28/2024.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) staff files reviewed all three staff lacked proof of required annual medication training. This poses/posed a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall ensure all staff handling residents medication receive the required annual medication training.
Submit proof by POC by due date. proof of the required annual medication training for staff assigned to dispense medications to resident.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Resident #3's needs and services plan was observed over a year old. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall complete get signatures and submit to LPA a copy of the updated Needs and services plan for Resident #3 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee/Administrator did not review the Emergency Disaster Plan annual since developed. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall review the Emergency Disaster Plan and update accordingly; if no updates needed then it should be signed and dated when it was reviewed annually. Submit copy of reviewed Emergency Disaster Plan with signature page. Also submit a letter of understanding the importance of ensuring that this procedure is followed annually.
Type B
Section Cited
CCR
87606(f)(3)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) staff records reviewed no staff had record of this training. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall ensure staff receive the above required training and submit proof of training 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. One out of five resident files reviewed identified that Resident #3 is receiving home health service; no written agreement between facility and home health agency was observed on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall meet with the home health agency and develop an agreement to meet this requirement.
Submit proof of written agreement by POC date.
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

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. Two out of five clients observed in their room with full urine bottles; one full sitting on the night stand/on the other several urine bottles on and near resident's bed. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall meet with staff; provide in-service and ensure resident rooms are clean and bottles filled with urine are emptied.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 03/21/2024 06:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four (4) out of five (5) resident medications reviewed it was observed that staff are not logging in all prescribed/nonprescribed medications on the Centrally Stored Record log for the four residents. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee/Administrator shall conduct a medication audit and provide training to staff on record keeping. Provide copy of the in-service training provided by POC date. Ensure all resident medications are logged on the Centrally Stored log and provide a copy of the centrally stored log for all four residents (R1,R2,R3,R4) by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215
VISIT DATE: 03/21/2024
NARRATIVE
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Staff records reviewed at approx. 12:45pm - Staff records were reviewed and noted to be complete for first aid certification, health screening documentation, employee rights and criminal record clearance. However no current training records found for the staff. Last training records observed for the required annual 20hrs was conducted in 2020.

Medications reviewed at approx. 2:30pm - Four (4) out of 5 residents centrally stored medication records were not updated with all prescribed/non-prescribed medications on hand. Staff admit that the centrally stored record is not up to date with medication on hand for the four residents.


Throughout the visit, LPA also conducted interviews with two staff and four (4) residents.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).
Exit interview conducted. Today's report was discussed and issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8