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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006078
Report Date: 03/12/2025
Date Signed: 03/12/2025 01:44:05 PM

Document Has Been Signed on 03/12/2025 01:44 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:ANGEL COMFORT CARE 1FACILITY NUMBER:
306006078
ADMINISTRATOR/
DIRECTOR:		SAMUEL MANALOFACILITY TYPE:
740
ADDRESS:9511 LANDFALL DRIVETELEPHONE:
(714) 964-8800
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 6DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Angelina Teves, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection and was greeted and granted entry by staff. LPA informed Administrator (AD) Angelina Teves the purpose of the inspection. The facility currently has six residents. LPA observed residents lounging in the living room watching tv and relaxing in their bedrooms.

The facility is a two-story home with four resident bedrooms, three staff bedrooms, one staff bathroom, two resident bathrooms, kitchen, dining room, living room, backyard, swimming pool and attached 2-car garage. Facility appears clean, safe and sanitary. All resident bedrooms had the required component and furnishings. Facility has extra clean linens for resident use in the hall closet. Restrooms are stocked with soap, toilet paper, and paper towels. Hot water in the bathrooms measured between116.7-120.2 degrees Fahrenheit in the resident bathroom located in the hall and in resident room four. LPA observed the kitchen to be clean. LPA observed that the sharps are locked in a drawer located in the kitchen and inaccessible to residents in care. LPA observed fire extinguishers in the kitchen and by the front door to be charged and have a service date of March 4, 2025. LPA observed the centrally stored medications were locked in a cabinet located in the garage and is inaccessible to residents in care. LPA observed the facility has emergency food and water supply. LPA observed that the toxins and chemicals are locked in a cabinet in the garage and under the kitchen sink making them inaccessible to residents in care. The backyard has a shaded seating area for client use and is free of debris and obstructions. The backyard has an in ground swimming pool that is fully enclosed by a wrought iron gate along with the perimeter fencing. The swimming pool gate swings away from the pool with a lock at the top. The fence is five feet five inches in height and the vertical bars are five and a half inches apart. There is one resident bathroom window that leads to the pool that does not have an alarm. Carbon monoxide detectors were found to not be operational.

Continued on LIC 809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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 03/12/2025 01:44 PM - It Cannot Be Edited


Created By: Hanna Gough On 03/12/2025 at 01:02 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: ANGEL COMFORT CARE 1
FACILITY NUMBER: 306006078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 working carbon monoxide detector which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Administrator stated that they will buy a new carbon monoxide detector and send proof of receipt and operation video to LPA by email or text by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hanna Gough
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 01:44 PM - It Cannot Be Edited


Created By: Hanna Gough On 03/12/2025 at 01:12 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: ANGEL COMFORT CARE 1
FACILITY NUMBER: 306006078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(1)
Incidental Medical

There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 medication reviews for a PRN prescription for resident #1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Administrator stated that they will obtain a prescription for the PRN medication and send it to LPA by POC due date via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hanna Gough
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


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: ANGEL COMFORT CARE 1
FACILITY NUMBER: 306006078
VISIT DATE: 03/12/2025
NARRATIVE
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LPA reviewed two staff files and no discrepancies were observed. All present staff were fingerprinted and associated to the facility. LPA reviewed six resident files and no discrepancies were observed. LPA observed the last fire drill conducted was on December 28, 2024. LPA reviewed six of six client medications of which one did not have a PRN prescription.

Based on today's observations citations were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Angelina Teves and a copy of this report was provided along with LIC 858, LIC 859,LIC 809-D and appeal rights .
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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