032700106-3-26-2025-27-AS-AVIA-DF5UYF-20250326155951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 032700106
Report Date: 03/26/2025
Date Signed: 03/26/2025 04:00:00 PM

Document Has Been Signed on 03/26/2025 04:00 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ANGELO'S CARE HOME		FACILITY NUMBER:	032700106
ADMINISTRATOR/ DIRECTOR:	FERRER, ANGELO		FACILITY TYPE:	735
ADDRESS:	652 GLENBROOK DRIVE		TELEPHONE:	(916) 601-9236
CITY:	IONE	STATE: CA	ZIP CODE:	95640
CAPACITY: 4		CENSUS: 4	DATE:	03/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:22 PM
MET WITH:	Staff on duty (S1)		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/26/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their required annual inspection visit. LPA was met with staff on duty, Jodelyn Delos Santos (S1) and stated the purpose of this visit. S1 then notified the home manager, Aaron Cocjin, of this visit and briefly spoke with LPA over the phone. At this time, Aaron is unable to come to the facility. Present during this visit were 2 clients in care with 2 staff on duty. The other residents in care were out in the community. This facility was vendorized to be able to accept and retain (4) adult residents at any given time. A tour of this facility was conducted. Facility is a one-story home located in residential neighborhood. Kitchen area was toured. Cabinets and drawers were inspected. Kitchen refrigerator has sufficient space to store enough food items. LPA observed 2 freezers - one in the kitchen and one in the garage. Refrigerator temperature was observed at 50 degrees Fahrenheit and freezer temperatures were observed to be above 0 degrees Fahrenheit - kitchen freezer was at 10 degrees Fahrenheit and garage freezer was at 8 degrees Fahrenheit. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication storage is located in the closet near the office, which was observed to be locked and made inaccessible to residents during this visit. A tour of 3 resident bedrooms and 2 restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured at 106.5 degrees Fahrenheit. Room temperature were observed at 71 degrees Fahrenheit during this visit. Air conditioner was observed to be running during this visit. {1 f 2}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELO'S CARE HOME	FACILITY NUMBER: 032700106
	VISIT DATE: 03/26/2025

NARRATIVE

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Facility was observed to have sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Laundry area was observed inside the garage. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Two fire extinguishers were observed - one in the kitchen/dining area and one in the garage - both were last serviced on 11/20/2024.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted and found to be in good repair at this time. During the inspection of the exterior, LPA observed 2 paint cans at the side of the house (garage side); they were placed near the condenser unit and were accessible to residents in care. S1 immediately removed both paint cans and stored them inside a locked cabinet in the garage.

Due to insufficient time, this annual inspection will need continuation. The Department will return at a later date to conduct a continuation visit.

Exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC809 (FAS) - (06/04)

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