565801598-9-9-2021-29-AS-MGCZ-C6PUDN-20210909152950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801598
Report Date: 09/09/2021
Date Signed: 09/09/2021 03:30:57 PM

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 III		FACILITY NUMBER:	565801598
ADMINISTRATOR:	JOANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	3216 YARDLEY PLACE		TELEPHONE:	(805) 581-9422
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 3	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Onorata Perla Avestro for JoAnn Trupiano		TIME COMPLETED:	03:30 PM

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Angels LIC 809Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced visit to Angels III to conduct a Required 1-Year Annual Inspection with focus on Infection Control. Last annual conducted was on 11-08-2019. LPA was greeted and screened at the door by staff Onorata Perla Avestro. LPA called and spoke with Administrator JoAnn Trupiano; however, she could not make it to the facility due to a family emergency. LPA explained the reason for the visit and Administrator gave Staff Onorata Perla Avestro permission to sign final report. Entrance interview conducted.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA along with Staff Onorata, initiated a tour at 1:10 pm and the following was observed:

There is a central entry point designated for universal screening for visitors by the entrance. At 1:27 pm, Smoke detectors and Carbon Monoxide detector were tested and functioned properly. LPA observed Fire extinguisher to be fully charged on January 18, 2021. There is a separate small office next to the living room. In this separate area, First-Aid Kit was observed to be complete. Medications are also store in the office off the living room in a locked cabinet. Main temperature displayed by hallway and read at 77 degrees Fahrenheit for the facility. LPA observed washing hands signs posted throughout facility.

OUTDOOR SPACE: LPA observed the backyard to have a covered outdoor area with a tables and chairs for resident use. There is one (1) gate on the side of the house that has a single latch and remains unlocked. There is a pool as well, but it has a lock on gate inaccessible to residents.

KITCHEN: LPA observed the kitchen/dining area to be clean. Knives are stored in a locked cabinet next to the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

-Continued on LIC 809

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGELS III	FACILITY NUMBER: 565801598
	VISIT DATE: 09/09/2021

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-Continued from LIC 809

BEDROOMS: LPA observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a nightstand, and adequate lighting. Each bedroom has two (2) beds, but each resident had a room to themselves. Beds were at least six (6) feet apart.

RESTROOMS: LPA observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats inside the shower. Water temperature was checked in two (2) resident bathrooms, at 1:13pm and 1:19pm both bathrooms read at 107.6 degrees Fahrenheit.

LPA observed at least a 30-day supply of Personal Protection Equipment (PPE).

The facility cleans the common areas at least twice daily.

If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

LPA observed CDSS PINs posted by the entrance accessible to residents and visitors.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Staff Onorata will sign for Administrator JoAnn Trupiano. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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