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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003809
Report Date: 08/15/2024
Date Signed: 08/15/2024 11:22:51 AM

Document Has Been Signed on 08/15/2024 11:22 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELS HOME LLCFACILITY NUMBER:
306003809
ADMINISTRATOR/
DIRECTOR:		ROBERT LEALFACILITY TYPE:
740
ADDRESS:9781 OMA PLACETELEPHONE:
(714) 530-7143
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Tiburcia DancelTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and William Vanegas made an unannounced visit for the purpose of conducting a Plan of Correction (POC) inspection. LPAs were greeted and granted entry by Staff Manuel Deldo. LPAs met with Staff Tiburica Dancel and explained the purpose of the inspection.

LPAs are following up on deficiencies cited on August 2, 2024. Deficiencies 87468.1(a)(3) and 87468.1(a)(16) were cited due to violation of resident’s personal rights. Licensee Marilou Leal indicated personal rights training would be conducted for all facility staff by POC date August 3, 2024.

During today’s visit, two of two staff present indicated staff training had yet to be conducted and is scheduled to take place on today’s date at 1 p.m.

Based on today’s observations, two deficiencies are being re-cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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Document Has Been Signed on 08/15/2024 11:22 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 08/15/2024 at 11:06 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME LLC
FACILITY NUMBER: 306003809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
CCR
87468.1

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...

This requirement is not met as evidenced by:
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Licensee stated staff training will be conducted regarding resident personal rights and a copy provided to LPA via email by POC.
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Based on S1 and Licensee admission, LPA determined that staff threatened client, which poses an immediate safety and personal rights risk to persons in care.
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Type A
08/16/2024
Section Cited
CCR8768.1(a)(16)

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To receive or reject medical care or other services.

This requirement is not met as evidence by:
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Licensee immediately called 911, and emergency services arrived to transport R1 to hospital. Licensee stated staff training will be conducted regarding resident personal rights and a copy provided to LPA via email by POC.
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Based on Licensee admission, they did not provided medical care to R1, after they sustained a fall resulting in an injury, which poses an immediate health and safety risk to persons in care.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


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