197610652-2-19-2025-31-AS-ASEA-DE2RPZ-20250219121246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610652
Report Date: 02/19/2025
Date Signed: 02/19/2025 12:12:59 PM

Document Has Been Signed on 02/19/2025 12:12 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CHRISTIAN ANGEL		FACILITY NUMBER:	197610652
ADMINISTRATOR/ DIRECTOR:	KAYIIRA, MARGARET N		FACILITY TYPE:	735
ADDRESS:	3931 SADDLE DRIVE		TELEPHONE:	(661) 383-3822
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 4		CENSUS: 0	DATE:	02/19/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Margaret Kayiira- Adminstrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE

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This is a Pre-licensing and this visit is to correct a previously completed report. See amended LIC809 report.

On 2/19/25, at around 10:30 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Abeye Duguma conducted an announced Pre-licensing visit. LPAs met with Administrator Margaret Kayiira.

An Initial license application to operate an Adult Residential Facility (ARF) was submitted on 07/15/2024. The requested capacity is for four (4) ambulatory clients. Fire clearance was approved on 07/05/2024.

LPAs conducted a physical plant tour and the following was noted:

Structure: The facility is a single-story building with four (4) bedrooms and three (3) bathrooms. One (1) room is designated staff room only.

Entrance: There is only one (1) entrance being utilized. Required postings such as: Facility Sketch, House Rules, and Rights of Individuals with Developmental Disabilities were observed immediately upon entrance.

Common Areas: These include both living room and dining room. All common areas were observed to be neat, clean, and organized. All common areas were properly furnished and in good repair. The facility maintains a comfortable temperature of sixty-one (61) degrees. No firearms observed or will be maintained on the premises.

Clients/staff files: Client and staff files will be kept in locked staff room inaccessible to clients.

Kitchen: Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods will be purchased prior to clients’ arrival. LPAs observed sufficient supplies of dishes, cups, and silverware readily available for the clients upon arrival. Working stove and refrigerator observed and in proper condition.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHRISTIAN ANGEL	FACILITY NUMBER: 197610652
	VISIT DATE: 02/19/2025

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Emergency: Fire extinguisher inspected and fully charged.

Medications: Medication along with Sharps will be stored in locked kitchen cabinet. Medication storage is equipped with a lock to ensure medications will not be accessible to clients. First-aid kit observed as well.

Bedrooms: All three (3) designated client bedrooms observed to be properly furnished with bed, nightstand, applicable lightening, and seating. Window coverings are in good repair, not broken or damaged.

Bathroom: The bathrooms are in proper condition and will be equipped with sufficient personal hygiene for each client. Towels and washcloths will not be shared.

Hallways: Hallway is properly lighted. Extra linens/covers will be stored in storage cabinets alongside hallways passageway.

Laundry: Laundry is located within hallway leading towards the bedrooms. Laundry room is kept locked. All cleaning solutions and toxins will be kept stored in locked cabinet inside the laundry room. Dryer and washer observed to be in good repair.

The Garage: The garage can be accessed from inside the facility. The garage will be used for extra storage and is kept locked.

Staff room: Staff room will be kept locked inaccessible to clients.

Water Temperature: The water temperature was measured within regulations at 119.0 Fahrenheit.

Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested around 11:00 AM.

Outside: The outside is clean, free of hazards, and properly furnished with sufficient seating. A shaded area for clients was observed as well.

Pool: No body of water located on premises.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHRISTIAN ANGEL	FACILITY NUMBER: 197610652
	VISIT DATE: 02/19/2025

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Administration: The facility had submitted an Emergency and Disaster Plan For Adult Community Care Facilities and Residential Care Facilities for the Chronically ill and Infection plan.

Administrator The Component III Orientation Adult Residential Facility (ARF) was shown/reviewed with the Administrator.

The facility is in compliance with Title 22 Regulations at this time. 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 conducted and copy of this report issued to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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