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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002275
Report Date: 05/23/2022
Date Signed: 05/23/2022 03:15:48 PM

Document Has Been Signed on 05/23/2022 03:15 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:ANGELS HOMEFACILITY NUMBER:
306002275
ADMINISTRATOR:RAFAEL A. TORRESFACILITY TYPE:
735
ADDRESS:12061 LORALEEN STREETTELEPHONE:
(714) 537-3413
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 3DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Marcelina Lived- Staff TIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by staff Marcelina Lived and explained the reason for the visit. Administrator Rafael Torres arrived at 2:00pm.

At 12:50PM LPA toured the facility with Staff Marcelina Lived.Facility is 5 bedroom, 3 bathroom single story home with a detached garage. Facility has 3 clients present during today's visit. LPA observed clients relaxing in the facility. Facility appears clean and sanitary. All clients rooms had the required elements as well as restrooms stocked with soap.. LPA observed supply of emergency food with packs of water. LPA observed locked medication cabinet. LPA toured the outside grounds and exit gates are unlocked and self latching. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and clients are vaccinated for Covid-19. LPA reviewed all client's files and all contained required documentation including updated emergency information.


Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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Document Has Been Signed on 05/23/2022 03:15 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 05/23/2022 at 01:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME
FACILITY NUMBER: 306002275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80086
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed LIC 999 Facility Sketch does not match current floor plan which poses a potential safety risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee to submit LIC 200 with updated floor plan to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022


LIC809 (FAS) - (06/04)
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