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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000507
Report Date: 02/14/2022
Date Signed: 02/14/2022 03:09:05 PM


Document Has Been Signed on 02/14/2022 03:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ANGEL GUEST CARE HOMEFACILITY NUMBER:
306000507
ADMINISTRATOR:GLADIOLIE M. MEDINAFACILITY TYPE:
740
ADDRESS:3148 W. ROME AVENUETELEPHONE:
(714) 761-9405
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 2DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Mary Jean Alvarado, ManagerTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA arrived at facility and was greeted by the caregiver present and granted entry after undergoing the facility's COVID-19 screening. LPA explained the purpose of the visit. Manager Mary Jean Alvarado arrived shortly after being called by caregiving staff.

At approximately 2:55pm, LPA accompanied by Administrator began the tour of the facility. There are currently 2 residents in care. The residents are observed relaxing in the common area and appear well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed a check-in station right at the entrance of the facility and visitors are observed being temperature screened upon entry. LPA observed the facility has COVID-19 Precautions posters, all required department postings, and hand washing signs. LPA observed the emergency food supply and water. Facility has an adequate supply of PPE stored in the attached garage. LPA toured the outside of the facility and observed outdoor seating for the residents' enjoyment. Outdoor space is free of debris and well-maintained. All bedrooms were observed to have all required components. Bathrooms are equipped with grab bars and slip mats.

The facility has completed the LIC808 Mitigation Plan, LPA Norman Woodridge reviewed and approved the plan on 07/28/2021. LPA Norman Woodridge emailed the signed and approved plan to the Administrator for their records.

Based on the observations made during today’s visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
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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