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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005151
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:13:19 PM

Document Has Been Signed on 07/12/2022 12:13 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:ANGIE'S HOMEFACILITY NUMBER:
306005151
ADMINISTRATOR:HO, DUNG VANFACILITY TYPE:
735
ADDRESS:1401 S JEFFERSON AVETELEPHONE:
(714) 733-9552
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 3DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator/Licensee, Dung HoTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a annual visit. LPA was granted entry. LPA introduced themselves and discussed the purpose of visit with Administrator Dung Ho.

During the visit LPA toured the facility. Facility is a 5 bedroom (4 client rooms,1 staff room) 2 bathroom, single story home. Home is a Level 2 Adult Residential Facility. There are 3 Clients in care. LPA observed proper covid signage at front entrance of facility as well as sanitization station upon entrance. Facility has required Department postings. LPA observed Emergency Disaster plan and observed copy of Administrators Certificate expiring 01/5/2023. LPA toured all clients rooms, rooms contained required furniture such as beds, dressers, night stands and lighting. All restrooms observed contained working wash basin, toilet, soap, toilet paper and hand towels. Bathrooms had proper hand washing signs posted. LPA observed an outside visitation area with shading. Clients were observed relaxing in bedrooms. Facility has connected operating smoke detectors. Facility has 4 fire extinguishers mounted and fully charged. Facility has ample emergency food and water supply. Facility has a secured location for sharps. Facility has a secured location for client medication and files. During today's visit LPA reviewed clients medications. Clients have 30 day supply of medications. LPA reviewed 3 clients files. Files reviewed had updated Emergency Contact information and Physician's reports. Facility had ample supply of PPE. Facility has a secured location for toxins and hazardous materials. During visit LPA discussed with Administrator/Licensee the importance of care, supervision of clients and updated medical reports.


No deficiencies noted during todays visit. An exit interview was conducted with Administrator Dung Ho and a copy of this report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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