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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032700106
Report Date: 03/23/2026
Date Signed: 03/23/2026 01:36:45 PM

Document Has Been Signed on 03/23/2026 01:36 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 HOMEFACILITY NUMBER:
032700106
ADMINISTRATOR/
DIRECTOR:		AARON COCJINFACILITY TYPE:
735
ADDRESS:652 GLENBROOK DRIVETELEPHONE:
(916) 601-9236
CITY:IONESTATE: CAZIP CODE:
95640
CAPACITY: 4CENSUS: 4DATE:
03/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Aaron Cocjin TIME VISIT/
INSPECTION COMPLETED:
01:48 PM
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On 03/23/2026, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with care staff Gracin Genardino and explained the purpose of the visit. Care staff contacted Administrator Aaron Cocjin to inform him that Community Care Licensing Division (CCLD) staff were present at the facility. A brief telephone interview was conducted with Administrator Cocjin. Approximately one hour and thirty minutes later, the Administrator arrived at the facility and joined the inspection. The Administrator’s certificate number is 7010261735, with an expiration date of 12/07/2027. The facility’s current census is four residents, with one staff present at the time of the visit.

This facility is a single story building licensed to serve four (4) ambulatory clients of two (2) may be non-ambulatory in room #1 and #2. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room, garage, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 118.2 degrees Fahrenheit in client bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. The smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in dining area and was last serviced on 11/24/2025. The last fire drill was conducted on 03/02/2026. LPA Lee observed the facility has a has a public telephone in the kitchen Facility thermostat was observed at 70 degrees Fahrenheit, which is within the required regulation of 68 to 85 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2026
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: 03/23/2026
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LPA Lee observed toxins and sharp knives located in the kitchen cabinet and kept locked and inaccessible to client. LPA Lee checked medication storage and found medication to be locked away and inaccessible to client. The first aid kit was checked and contained the required components.

During the inspection, it was learned that the facility is in the process of adding an additional room at the back of the facility adjacent to resident room #3. The addition is currently connected to the closet of resident room #3; however, a wall will be installed to enclose and separate the two spaces. The Administrator also stated that the bathroom in resident room #3 will be converted into a common bathroom for resident use, as it is more suitable, and will be enclosed so that it is no longer connected to bedroom #3. According to the Administrator, Cocjin, the facility has obtained the necessary permits for the construction. The Administrator further reported that the addition was communicated to LPA Villanueva and that the assigned LPA Viarella was also notified via phone and email. During today’s visit, LPA Lee obtained copies of the permit documents.

LPA Lee and care staff Genardino audited medications for 4 out of 4 clients by comparing the medications on hand with their Medication Administration Records (MARs) and confirmed that all records were accurate and complete. LPA Lee reviewed 4 out of 4 client files, and they were complete. LPA Lee reviewed 2 staff files, and it was also complete. LPAs reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated with the facility.


The following documents will be emailed to LPA Lee at pang.lee@dss.ca.gov by end of day 03/27/2026 5:00 PM:

(1) LIC 308 Designation of Administrative Responsibility


(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Administrator Cocjin, a copy of these LIC 809 reports was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC809 (FAS) - (06/04)
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