197610406-5-3-2023-31-AS-APAA-CRGPJ7-20230503112105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610406
Report Date: 05/03/2023
Date Signed: 05/03/2023 11:21:55 AM

Document Has Been Signed on 05/03/2023 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMAZING ANGELS		FACILITY NUMBER:	197610406
ADMINISTRATOR:	WERDIAN, LUSINE		FACILITY TYPE:	735
ADDRESS:	14268 PIERCE ST		TELEPHONE:	(818) 455-9929
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY: 4		CENSUS: 0	DATE:	05/03/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lusine Werdian, Administrator		TIME COMPLETED:	11:50 AM

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At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an announced Pre-Licensing visit to this facility and met with the Administrator. This is an initial application. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

Facility Fire clearance was conducted on 03/30/23 and approved for four (4) Ambulatory clients only. The facility has dual carbon monoxide and smoke alarm system. There is a fire extinguisher located in the kitchen with a date of purchase of 01/09/2023. There will be a functioning telephone on the premises. An emergency exit plan/sketch is posted in each bedroom and in the hallway wall with other posting requirements. There are four (4) bedrooms designated for clients use. Clients bedrooms were observed to be appropriately furnished. The facility will have an awake staff. There are two (2) bathrooms in the facility. Bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to have closed tight fitting lids.

The common areas (living room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Clients, staff records and medication will be stored in a locked kitchen cabinet. The first aid kit is readily available.

The kitchen knives are stored in a locked drawer. The kitchen cleaning supplies are stored in a locked cabinet under the sink. Laundry detergents, cleaning supplies and other toxins are stored in an attached garage. LPA observed the garage to be locked and inaccessible to clients in care. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMAZING ANGELS	FACILITY NUMBER: 197610406
	VISIT DATE: 05/03/2023

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There will be a sitting area in the backyard for residents to conduct outdoor activities. The outdoor, front and back yards were free of any obstruction. There is no body of water.

Component III was conducted with applicant.

No deficiencies issued with this report. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted. A copy of this report was signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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