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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201117
Report Date: 12/17/2021
Date Signed: 12/17/2021 12:30:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANGEL'S LOVE RCFE 2FACILITY NUMBER:
079201117
ADMINISTRATOR:BADEO, MARCELINAFACILITY TYPE:
740
ADDRESS:2030 TIOGA PASS WAYTELEPHONE:
(925) 876-0605
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 4DATE:
12/17/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marcelina Badeo, AdministratorTIME COMPLETED:
11:00 AM
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Component II completion: Unsuccessful

Facility Type: RCFE
Application Type:Change of Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 4 (3 non-ambulatory, and 1 bedridden)
COMP II Participants: Marcelina Badeo, Administrator
Interview Method: Telephone interview

On December 17, 2021 at 10:00 AM, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. Administrator did not provide sufficient knowledge the program and the California Code Title 22 Regulations. Component II will be rescheduled.

Exit interview conducted with Administrator and LIC 809 sent to Administrator via email. Administrator informed to return sign LIC 809 to CCLD before next COMP II.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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