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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003809
Report Date: 12/02/2024
Date Signed: 12/02/2024 05:02:30 PM

Document Has Been Signed on 12/02/2024 05:02 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
ORANGE COUNTY RO, 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: DATE:
12/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregivers Tiburcia Dancel and Manuel Delvo and explained the reason for the visit. Administrator (AD) Marilou Leal arrived shortly to assist with the visit. Facility is licensed for four non-ambulatory residents, two ambulatory residents with a hospice waiver for one. Currently there are five residents.

Around 1:29 PM, LPA Tea reviewed five resident files and two staff files. There were discrepancies noted in the review of resident and staff files. AD Leal administrator certificate expires on January 31, 2025.



LPA Tea along with the Administrator toured the facility at 2:25 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 5 resident bedrooms, 1 caregiver room, 3 bathrooms, living room, dining room, kitchen, and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 119.6 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had the required elements including bandages, thermometer, and scissors. The only item missing were the tweezers, which the AD Leal will purchase. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps are supposed to be locked in a kitchen cabinet but was not secured at the time of LPA’s observation during facility tour. Staff immediately locked up the sharps upon LPA’s discovery. LPA also observed toxin substances to be locked and inaccessible to clients in care locked and secured in cabinets in the garage. The fire extinguishers throughout the facility were fully charged. Kitchen appliances are operational during today's visit.

Annual Inspection continued on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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 12/02/2024 05:02 PM - It Cannot Be Edited


Created By: Michael Tea On 12/02/2024 at 04:08 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME LLC
FACILITY NUMBER: 306003809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff records, one staff does not have current first aid/CPR training. Which poses as a potential health and safety risk to residents in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee/Administrator will provide proof of first aid/CPR training for staff by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's review of staff records, there were no annual staff training on file. This could pose a potential health and safety risk to residents in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee/Administrator will provide proof of completed annual 20 hour staff training by POC due date.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELS HOME LLC
FACILITY NUMBER: 306003809
VISIT DATE: 12/02/2024
NARRATIVE
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 LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility are self-latching and operational. There is a barbecue grill used during the summers. LPA observed emergency supplies, food and water in the garage. Facility provides activities based on resident interests. The residents goes for walks around the neighborhood, watch television, listen to music, reading books and newspapers and crafting bracelets and necklaces. They also go on outings, like shopping on Saturdays and church on Sunday and eat lunch together outside. At the time of annual visit, residents were seen crafting, reading newspapers and watching television in the living room.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician orders. All P&I Funds are accounted for and there are no discrepancies. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Marilou Leal and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102 and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
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