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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201117
Report Date: 01/05/2022
Date Signed: 01/05/2022 12:53:55 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: 3DATE:
01/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marcelina Badeo, Applicant/LicenseeTIME COMPLETED:
12:50 PM
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On 12/16/2021 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a Change of Ownership Pre-licensing Required inspection. LPA met with Applicant/Administrator and explained the purpose of the visit. The facility currently has 3 residents.

Facility has an approved fire clearance dated 12/09/2021 for 6 residents. There are 5 bedrooms and 2 bathrooms. Posters including but not limited to Covid-19 related posters, complaint poster, Personal Rights were observed. All bedrooms were observed furnished with a bed, dresser, closet, nightstand, lamp and chair. Hallways and passageways were free of obstruction. There was sufficient lighting and furniture. The kitchen was observed clean and organized. There was sufficient supply of non-perishable foods observed. Plates, silver wares and glass wares were observed available. A copy of menu was posted on the refrigerator. Hot water measured at 119 F. There was a locked cabinet for medicine and resident files. Knives and other sharp objects and chemicals were kept in a locked drawer and cabinets in the kitchen & garage. There was sufficient supply of towels, sheets, blankets and hygiene products observed.

Smoke detector and carbon monoxide were tested and observed operational. First aid kit was complete. There were activity materials available. Facility has a washer and dryer installed in the laundry room. There were no bodies of water observed.

LPA observed that facility is ready to be licensed. No deficiencies were observed during visit. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report was provided to Applicant via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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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