<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005151
Report Date: 07/31/2024
Date Signed: 07/31/2024 04:36:14 PM

Document Has Been Signed on 07/31/2024 04:36 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGIE'S HOMEFACILITY NUMBER:
306005151
ADMINISTRATOR/
DIRECTOR:		HO, DUNG VANFACILITY TYPE:
735
ADDRESS:1401 S JEFFERSON AVETELEPHONE:
(714) 733-9552
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 3DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Stafff Kendrick HoTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 On 7/31/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA were greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Dung Ho was present to assist with the facility inspection on today's date.

The facility is licensed for six (6) ambulatory Developmentally Disabled clients. Facility is a level two home. Currently, there are three (3) client's present during today’s visit.
This is a single story home with attached garage facility. The facility has Five bedrooms ( 4 clients and 1 staff ) with two bathrooms.
At around 2:15 PM. LPA conducted a tour of the physical plant accompanied by Administrator Ho, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 113.1 degrees F. A comfortable temperature of 78 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. LPA observed facility has emergency food and water supply facility has two fire extinguishers that were mounted and was charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.


CONTINUED ON 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGIE'S HOME
FACILITY NUMBER: 306005151
VISIT DATE: 07/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors and clients and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE).
LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 2/26/24 The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 4/1/2023 - 4/1/2027.
A review of three clients (C1-C3) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Dung Ho # 6030269735 - Expiration 1/05/2025.

No deficiencies during this inspection visit. A exit interview was conducted with Administrator and a copy of report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5