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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600180
Report Date: 05/19/2021
Date Signed: 07/21/2021 05:09:11 PM

Document Has Been Signed on 07/21/2021 05:09 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ANGELINA HOME AND CARE IIIFACILITY NUMBER:
198600180
ADMINISTRATOR:ADELINA B. ESGUERRAFACILITY TYPE:
735
ADDRESS:3036 LA PUENTE ROADTELEPHONE:
(909) 598-8323
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 6DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Flordeliza RosanaTIME COMPLETED:
03:15 PM
NARRATIVE
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting the Required annual inspection. On today's visit LPA met with Caregiver, Flordeliza Rosana, who assisted with today's visit. Administrator, Adelina B. Esguerra was unable to come to the facility on today's visit. Ms. Esguerra was available by telephone and discussed infection control practices with LPA Rea.

LPA Rea toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed a sample of resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front yard is well maintained. The hot water temperature measured between 105-120 degrees. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility. There is a carbon monoxide detector in the dining area.

LPA observed that the facility is not currently maintaining a visitor sign in log, and is not requesting visitors to sanitize their hands upon entering the facility.

Deficiencies cited on 809-D. Copy of report, and appeal rights provided to Ms. Rosana.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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 3
Document Has Been Signed on 07/21/2021 05:09 PM - It Cannot Be Edited


Created By: Angelica Rea On 05/19/2021 at 02:46 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(c)
Health-Related Services
(c) The isolation room or area specified in Section 80087(d) shall be used where separation from others is required.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2021
Plan of Correction
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Hand washing and/or hand sanitizer to be requested from all staff, residents and visitors upon entry of the facility.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/21/2021 05:09 PM - It Cannot Be Edited


Created By: Angelica Rea On 05/19/2021 at 02:46 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELINA HOME AND CARE III
FACILITY NUMBER: 198600180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80078(a)
Responsibility for Providing Care and Supervision
(a)The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2021
Plan of Correction
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Administrator shall ensure that the facility keeps a sign in log for all visitors to the facility.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3