198204584-3-10-2023-11-AS-EDAT-CPSV3G-20230310150442

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204584
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:05:04 PM

Document Has Been Signed on 03/10/2023 03:05 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:	VILLA ANGELA RESIDENTIAL HOME		FACILITY NUMBER:	198204584
ADMINISTRATOR:	SHIRLEY DANTING		FACILITY TYPE:	740
ADDRESS:	23528 FIGUEROA STREET		TELEPHONE:	(310) 835-6773
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 6		CENSUS: 6	DATE:	03/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:01 AM
MET WITH:	Shirley Danting		TIME COMPLETED:	03:12 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	On 03/10/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the administrator Shirley Danting. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults over the age of 60 and above Currently, the home has (5) residents and (1) on hospice care. The facility is approved for (4) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) residents' rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, a den, an outside patio, and a garage LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. The water temperature measured 109.8 degrees F. A comfortable temperature was maintained in the facility at 73 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. (Evaluation Report continues LIC 809-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA ANGELA RESIDENTIAL HOME	FACILITY NUMBER: 198204584
	VISIT DATE: 03/10/2023

NARRATIVE

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DEFICIENCIES:
LPA identified the following deficiencies during inspection visit:

Resident #1-#3: resident with dementia no current medical assessment or appraisals.
Staff #5-#7: no current First Aid/CPR certificate on file.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Shirley Danting and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared.*

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/10/2023 03:05 PM - It Cannot Be Edited

Created By: Ernand Dabuet On 03/10/2023 at 02:37 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: VILLA ANGELA RESIDENTIAL HOME	FACILITY NUMBER: 198204584
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(5)(6)

(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA identified R1-R3 with dementia and required current medical and appraisal assements. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will comply to Title 22 Section 87705 and ensure residents with dementia must have annual medical and appraisals for resident #1-#3. Proof of correction must be submitted to LPA by due date 04/10/23.

Type B

Section Cited

CCR

87411(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA identified staff #5-#7 did not have current First Aid/CPR certificates on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Licensee/Admnistrator will comply to Title 22 Section 87411 and ensure that all direct staffd working with residents in care must have valid First Aid/CPR certificate on file. Proof of correction must be submitted to LPA by due date 03/24/23.

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Ernand Dabuet

LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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