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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320274
Report Date: 01/18/2023
Date Signed: 02/13/2023 03:18:58 PM

Document Has Been Signed on 02/13/2023 03:18 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANGEL HOUSE, THEFACILITY NUMBER:
198320274
ADMINISTRATOR:JOHNSON, SOPHESIASFACILITY TYPE:
735
ADDRESS:5103 W. 123RD PLACETELEPHONE:
(562) 405-7316
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 3CENSUS: 0DATE:
01/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Sophesias JonsonTIME COMPLETED:
11:45 AM
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On January 18, 2023, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an announced pre licensing visit with Administrator, Sophesias Johnson. The facility will be operating as an Adult Residential Facility and has requested the capacity for 3 occupancies. The fire safety inspection request was approved for 3 ambulatory residents.

Structure The facility is a single-story home in a residential neighborhood. The facility consists of 3 bedrooms, 2 bathrooms, a living room, dining room and kitchen.

Physical Plant LPA walked through the facility inside and out. The front is well landscaped and maintained. The backyard is landscaped and well maintained. The backyard has a shaded patio that contains a table and chairs for residents; as well as a washer and dryer, locked cabinet with additional cleaning supplies, and a locked box for their emergency go bags. The exit gate from the back is not locked and easily accessible for evacuation. There is a garage and shed in the backyard that is not being used by the facility and can only be accessed by the owner. All walkways are clear of obstructions, debris or hazards. No bodies of water were observed

Bedrooms There are three (3) resident rooms. Each room had the required furnishings including bed, nightstand with a lamp, chair, and dresser. All beds have the required linens including a mattress cover, fitted sheets, blanket, comforter and pillow. All rooms have ample closet space and lighting.

Bathrooms Both bathrooms were inspected. Bathroom one (1) was in good working order. It had a functioning shower, toilet and two (2) sinks. Also, in bathroom one (1) there is an armoire cabinet for storage. Bathroom two (2), located in bedroom 3 had a functioning shower, toilet, and sink. Both showers had nonskid mats. In both bathrooms there was an ample supply of lighting, hand soap and paper towels. The water temperature in both bathrooms measured between 116.4- to 118.2- degrees Fahrenheit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANGEL HOUSE, THE
FACILITY NUMBER: 198320274
VISIT DATE: 01/18/2023
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Linens & Hygiene Provided for each client is a container that has toiletries, including shampoo, body wash, brush, lotion, toothbrush, toothpaste, and deodorant. An ample supply of towels, sheets and comforters are stored in the armoire cabinet in bathroom one (1).

Kitchen All appliance in the kitchen were in good working condition. They consist of a dishwasher, microwave, stove/oven and a refrigerator. All cutleries were in good condition. LPA observed a 7-day supply of nonperishable foods. Sharps and toxins are stored in a locked cabinet in the dining room. The water temperature measured at 118.1 degrees Fahrenheit.

Common Areas The dining room consist of a long table and 4 chairs. Additionally, there is a locked cabinet for storage. The living room has ample seating for all possible residents. There are games and books available for residents. There is a fireplace that is covered by a long cabinet and is inaccessible. All rooms have ample lighting.

Safety LPA observed 6 functioning smoke/carbon monoxide detectors and 2 additional carbon monoxide detectors. There is a fire extinguisher mounted on the wall in the kitchen. LPA found the landline to be functioning. All exits are marked, and facility sketch plans are posted. LPA observed four (4) First Aid Kit and manuals. At the entrance there is a sanitizing station, thermometers and log sheet for visitors.

Knives and Toxins Knives and cleaning supply are stored in a locked cabinet in the dining room.

Medication and Files Medications and files will be stored in a locked cabinet in the dining room.

Pre Licensing Component III was read and reviewed


An exit interview was conducted and a copy of this report was provided to Licensee.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023
LIC809 (FAS) - (06/04)
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