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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607962
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:08:12 PM

Document Has Been Signed on 06/23/2021 03:08 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:QUEEN OF THE ANGELS ASSISTED LIVING INC.FACILITY NUMBER:
197607962
ADMINISTRATOR:TERRY & MARY MCGEEFACILITY TYPE:
740
ADDRESS:420 S. MANNINGTON PLACETELEPHONE:
(626) 430-7702
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 6DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maryanne Vergara (Caregiver)TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Maryanne Vergara and explained the purpose of the visit. The facility is licensed to serve elderly residents age 60 and above. Facility fired cleared for two (2) ambulatory and four (4) non-ambulatory residents age 60 and above. Approved to accept or retain one (1) resident on hospice.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, sun room, family room, kitchen, dining room, 5 resident bedrooms, 1 staff room, office area, laundry area and 3 bathrooms. The bathrooms are clean and operational. Resident bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature tested at 110 degree F in bathroom #3. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. A shaded area with chairs is provided in the back yard. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. There is a fenced pool in the backyard. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet resident needs were observed. LPA was allowed to enter the facility to conduct the inspection. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Maryanne Vergara.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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