198203450-1-17-2023-11-AS-MLEN-CN6UHG-20230117143556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203450
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:36:28 PM

Document Has Been Signed on 01/17/2023 02:36 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ANGEL CARE IV		FACILITY NUMBER:	198203450
ADMINISTRATOR:	MAGPILE, MYLENE		FACILITY TYPE:	740
ADDRESS:	627 N. PAULINA AVE.		TELEPHONE:	(310) 372-0674
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90277
CAPACITY: 6		CENSUS: 5	DATE:	01/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:12 PM
MET WITH:	Joy Black, Co-Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Mario Leon conducted an unannounced required annual visit with a primary focus on Infection Control measures. Upon arrival at the facility, LPA met with Joy Black, Co-Administrator (CA1) and the purpose of today's visit was explained. LPA and CA1 took a tour of the physical plant. The facility is licensed for six (6) non-ambulatory residents and an approved hospice waiver for six (6) residents; 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 with a 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 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 protocols, 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 has outside visitation area located in the shaded backyard, and inside visitation available as well. LPA observed all staff wearing face coverings. 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 temperature measured at 114.9 F in bathroom one (1) and 115.3 F in bathroom two (2). Comfortable temperature of 69.4 was maintained in the facility.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL CARE IV	FACILITY NUMBER: 198203450
	VISIT DATE: 01/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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, locked and inaccessible to residents in care. The facility has two (2) Fire Extinguishers, which were checked and found to be fully charged and accessible. The First Aid kits were 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. Common areas were clean and clear of hazards; one doorway from Room D were blocked by chair. No bodies of water present.

One deficiency was cited during this visit, see LIC809-D.

An exit interview was conducted, and a copy of this report LIC809, LIC809C and LIC809D were provided to facility representative, Joy Black (CA1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/17/2023 02:36 PM - It Cannot Be Edited

Created By: Mario Leon On 01/17/2023 at 02:14 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL CARE IV	FACILITY NUMBER: 198203450
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Licensing Program Analyst Mario Leon's observation, the licensee did not comply with the section cited above in the fact that outside of room D, there was a chair which may block resident from exiting during an emergency, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2023
	Plan of Correction
1 2 3 4	Joy Black, Co-Administrator, immediately removed the chair, as mentioned above, while LPA Leon was on-site.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Mario Leon

LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3