<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700321
Report Date: 12/16/2022
Date Signed: 12/16/2022 10:47:49 AM

Document Has Been Signed on 12/16/2022 10:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:ANGEL CONNECTION NURSING SERVICESFACILITY NUMBER:
194700321
ADMINISTRATOR:MERJILYN CHUFACILITY TYPE:
300
ADDRESS:5000 E SPRING ST STE 400TELEPHONE:
(562) 420-4695
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: CENSUS: DATE:
12/16/2022
Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Laila DominguezTIME COMPLETED:
10:45 AM
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
Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Angel Connection Nursing Services on 12/16/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Laila Dominguez. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with designee and informed the designee that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 1