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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003809
Report Date: 10/04/2022
Date Signed: 10/04/2022 03:28:24 PM


Document Has Been Signed on 10/04/2022 03:28 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 HOME LLCFACILITY NUMBER:
306003809
ADMINISTRATOR:ROBERT LEALFACILITY TYPE:
740
ADDRESS:9781 OMA PLACETELEPHONE:
(714) 530-7143
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 5DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Divorcia Dancel -CaregiverTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Andrea Mendivil and Alvaro Ramirez conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Caregiver Divorcia Dancel and explained the reason for the visit. Administrator Marilou Leal arrived at 3:02 PM.

At 2:05 PM, LPAs toured the facility with Caregiver Divorcia Dancel. Facility is 5 resident bedrooms, 2 resident bathrooms, and 1 staff bathroom, one story home with two attached garages. Facility has 3 residents present during today's visit. LPAs observed a screening and sanitizing station at entrance of the facility. LPAs observed residents relaxing in their room and living room watching TV. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Facility has 1 refrigerator with ample food supply. LPAs observed facility has 72-Hour emergency food and water supply. Facility has a secured location for resident medication and files. LPAs toured the outside grounds and observed outside visitation area. Exit gates are unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPAs reviewed all residents’ files and all contained required documentation including updated emergency information. All staff and residents are vaccinated for COVID 19.

No deficiencies were noted during today's visit. This report was discussed with the facility representative and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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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