198320394-8-18-2023-11-AS-ARID-CUTT7N-20230818142902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320394
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:29:15 PM

Document Has Been Signed on 08/18/2023 02:29 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'S ON WING'S LLC		FACILITY NUMBER:	198320394
ADMINISTRATOR:	CLANTON, MARILYN		FACILITY TYPE:	740
ADDRESS:	1440 W 92ND STREET		TELEPHONE:	(310) 684-8859
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90047
CAPACITY: 6		CENSUS: 0	DATE:	08/18/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	07:52 AM
MET WITH:	Clanton Marilyn		TIME COMPLETED:	02:45 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 08/18/23, Licensing Program Analyst (LPA) Antonine Richard conducted an announced visit to the facility for purpose of a pre licensing evaluation. LPA was greeted by applicant Marilyn Clanton and explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 04/24/23 in the initial license application for a Residential Facility for the Elderly, ages 60 years and older. The applicant requested a capacity of six (6) individuals, of which four (4) ambulatory, two (2) non-ambulatory, and zero (0) bedridden. Structure: The home is a six (6) bedroom, two (2) bathroom, one-story home situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living room had sofa, chairs and coffee table. The activity room area with included recliners. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools. The patio contained one (1) table and six (6) chairs. Bedrooms Residents: The facility have six (6) bedrooms for residents. There are two (2) bedrooms for non-ambulatory residents and four (4) of the bedrooms specific for the ambulatory. All rooms include a twin size bed, one (1) chair, one (1) nightstand, one (1) trash ban with a lid, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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 6

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'S ON WING'S LLC	FACILITY NUMBER: 198320394
	VISIT DATE: 08/18/2023

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

Bedrooms Staff:
There is no bedroom designated for live-in staff. There is no staff lounge area.

Bathrooms:
The home has two (2) bathrooms. Bathrooms are accessible in all rooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet inside the bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are three (3) fire extinguishers located throughout the home. A telephone line is available in the kitchen, living, and activity rooms. Emergency supplies and Personal Protective Equipment supplies are stored in the cabinet. The applicant submitted a Mitigation Plan on 04/24/23.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer. Food supply is adequately stored in kitchen cabinets and consists of the can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all six (6) bedrooms and hallways. Carbon monoxide is combined with smoke detectors a total of ten (10).

Toxins:
All toxins are locked and stored in the laundry room in locked cabinets.

Evaluation Report Continues

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

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'S ON WING'S LLC	FACILITY NUMBER: 198320394
	VISIT DATE: 08/18/2023

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

Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which include toaster, microwave, and coffee maker. There is one (1) refrigerator in the home. The refrigerator measured a temperature of at least 45 degrees Fahrenheit for appropriate food storage. The home is equipped with central heaters and air conditioning systems.

Water Temperature:
The water temperature is 114. 4F degrees throughout the kitchen and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the living room cabinet inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident's medications will be stored in the medication cabinet locked in the hallway and inaccessible.

Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in the licensee office.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the activity room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Evaluation Report Continues

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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'S ON WING'S LLC	FACILITY NUMBER: 198320394
	VISIT DATE: 08/18/2023

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

Fire clearance:
A Fire Clearance inspection was conducted on 05/24/23 approved for a capacity for two (2) non-ambulatory, four (4) for ambulatory, and zero (0) for bedridden.

Pre-licensing Checklist:
Completed by licensee and reviewed by LPA.

Component III:
LPA Richard Conducted at the Pre-Licensing visit, along with the information provided about how to operate the facility within substantial compliance with Component III Power Point.

During the pre licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of, LPA Antonine Richard (Antonine.Richard@dss.ca.gov) (323-516-4092) by 08/25/2023. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. All outdoor passageways stairways, inclines, ramps and open porches,need to be equipped with sturdy hand railings and well-lighting.

2. The licensee will order a backup portable generator at Home Depot.

END OF REPORT

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6