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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203450
Report Date: 01/24/2022
Date Signed: 01/25/2022 12:07:56 PM

Document Has Been Signed on 01/25/2022 12:07 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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME:ANGEL CARE IVFACILITY NUMBER:
198203450
ADMINISTRATOR:MAGPILE, MYLENEFACILITY TYPE:
740
ADDRESS:627 N. PAULINA AVE.TELEPHONE:
(310) 372-0674
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90277
CAPACITY: 6CENSUS: 5DATE:
01/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Joy BlackTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with staff M. Maximo and conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. Back up Administrator Joy Black was present and assisted LPA with tour of the physical plant, the purpose of today’s visit was explained. The facility is licensed for six (6) non-ambulatory residents and an approved hospice waiver for six (6) resident; prefers to serve elderly age 60 and above.

The one story residential house consists of six (6) resident bedrooms, kitchen, dining area, living room, three (3) residents bathrooms, staff quarter (located in the back of the house), garage, washer/dryer located in garage, and backyard and side shaded patio, front landscape and yard was well maintained at time of visit.

During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms, temperature was checked. LPA observed a sanitizing station at the facility entrance; a visitors log with Covid-19 screening, PPE supplies are readily available with an additional 30 day supply of PPE in stock. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s has outside visitation area located in the shaded backyard or side patio, and inside visitation if vaccination and covid-19 test results are available. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility. CCLD PINS were readily available to staff and residents.

All rooms were inspected, bedrooms are private, one resident per room. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Resident bathrooms were checked, sufficient liquid soap and towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, the water

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: ANGEL CARE IV
FACILITY NUMBER: 198203450
VISIT DATE: 01/24/2022
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temperature measured at 118.8 degrees F in bathroom. Comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven day supply of non-perishable food. Knives and toxins were locked. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. The facility has one (1) Fire Extinguisher, which was checked and found to be fully charged, accessible, and inspected on March/2021. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No bodies of water present.

No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report LIC809 and LIC809C was provided to facility representative, Joy Black.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC809 (FAS) - (06/04)
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