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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006257
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:25:04 PM

Document Has Been Signed on 08/14/2024 01:25 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 CARE GUEST HOME IIFACILITY NUMBER:
306006257
ADMINISTRATOR/
DIRECTOR:
JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:432 N. COLORADO STREETTELEPHONE:
(714) 244-5885
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ruby CruzTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted by staff and granted entry. LPA informed staff of the reason for the visit. Staff called the Administrator and informed them of the visit. LPA and staff toured the facility. Ruby Cruz arrived during the visit and LPA explained the reason for the visit. The facility has 4 resident bedrooms, 2 bathrooms, living room, dining room, kitchen and an attached 2 car garage. LPA observed the See Something Say Something poster (PUB 475) posed next to the front door. LPA and staff toured the garage. LPA observed the garage has two new rooms. Staff reported that staff live in the 2 rooms. LPA observed each room has a locking door and has a bed and nightstand. Each room has a smoke detector. The main garage door can be opened and closed. There is also an exit door leading to the backyard. The washer and dryer are in the garage. The 2 rooms in the garage are not on the original facility sketch that was submitted with application to be licensed. LPA observed the resident rooms were clean and organized. Both bathrooms are clean and organized. Hot water measured 129.3 degrees Fahrenheit in bathroom 1 and 129.5 degrees Fahrenheit in bathroom 2. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The 4 burner gas stove lights unassisted. The fire extinguisher in the kitchen is fully charged. LPA observed the medication is kept locked in the hall closet. LPA observed the living room has 2 couches, a table and a large screen TV. There is no fireplace in the facility. LPA and staff toured the backyard. The exit gate is operational and self closing. No bodies of water observed. There are two tables with umbrellas and chairs to provided shaded seating on the deck. No obstacles or hazards observed in the backyard. The smoke detectors/carbon monoxide detectors tested operational. LPA reviewed 5 resident medications. LPA observed that 2 tablets and 1 capsule for Resident 1 (R1) are being stored outside of their original container and kept in a plastic pour cup with a lid. LPA reviewed 5 resident records, no discrepancies observed. LPA reviewed 3 staff files, no discrepancies observed. All staff files reviewed had the required training. LPA inspected the first aid kit. The first aid kit had all the required elements. The last fire drill took place on August 4, 2024. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 3
Document Has Been Signed on 08/14/2024 01:25 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 08/14/2024 at 12:53 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 CARE GUEST HOME II

FACILITY NUMBER: 306006257

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, LPA observed the garage has 2 new rooms which are not on the original facility sketch which was used for the original fire clearance granted on July 28, 2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee agrees to complete a new LIC 200 along with a new facility sketch requesting a new fire clearance for the facility. Licensee to forward the required documents to the LPA by the 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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/14/2024 01:25 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 08/14/2024 at 12:53 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 CARE GUEST HOME II

FACILITY NUMBER: 306006257

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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, LPA measured the hot water, 129.3 degrees Fahrenheit in bathroom 1 and 129.5 degrees Fahrenheit in bathroom 2. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee agrees to adjust the hot water to meet the regulation requirements. Licensee agrees to keep a hot water temperature log to make sure the water temperature is kept at the proper temperature.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 6 residents (LPA observed R1 had 2 tablets and 1 capsule stored in a plastic cup) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Licensee agrees to store all medication in its original container. Licensee agrees to train all staff on CCR 87465. Licensee to submit proof of training to LPA by the 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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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