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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320476
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:15:22 PM

Document Has Been Signed on 10/24/2024 12:15 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ANGELS FOR AGNES, LLCFACILITY NUMBER:
198320476
ADMINISTRATOR/
DIRECTOR:		SLUSHER, STEPHANIEFACILITY TYPE:
740
ADDRESS:152 E 110TH STREETTELEPHONE:
(213) 716-6494
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 4CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:18 AM
MET WITH:Stephanie Slusher - LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 10/24/2024, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced pre-licensing visit using the CARE Inspection Tool. LPA met with the Administrator Stephanie Slusher. LPA Troy Watson explained the purpose of today’s visit. Facility is licensed for (4) ambulatory residents ages 60 and up. The facility consists of (3) resident bedrooms, (1) bathroom, (1) living room, (1) dining room, outside patio are (1) kitchen and (1) laundry area.

LPA Watson toured the physical plant with the Administrator. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the smoke/carbon monoxide detectors combo and found that they were in operable condition. The water temperature properly measured between: 114°F and 116°F, between the bathrooms and in the kitchen.

Evaluation Report Continues LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ANGELS FOR AGNES, LLC
FACILITY NUMBER: 198320476
VISIT DATE: 10/24/2024
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LPA Troy Watson observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Sharps objects and cleaning agents were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the property. All fire extinguishers were charged and were operable. Because the administrator currently has no staff except herself only one personnel file was reviewed. The first AID kit was checked and contained the correct manual, tweezers, scissors, tape, and gauze. LPA observed the facility's infection control practices. All required postings were displayed and present at the facility. And copy of the liability insurance was on file.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Stephanie Slusher.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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