306005151-7-29-2025-22-AS-SHAN-DK2NK6-20250729103127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005151
Report Date: 07/29/2025
Date Signed: 07/29/2025 10:33:57 AM

Document Has Been Signed on 07/29/2025 10:33 AM - 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 HOME		FACILITY NUMBER:	306005151
ADMINISTRATOR/ DIRECTOR:	HO, DUNG VAN		FACILITY TYPE:	735
ADDRESS:	1401 S JEFFERSON AVE		TELEPHONE:	(714) 733-9552
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY: 6		CENSUS: 3	DATE:	07/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:19 AM
MET WITH:	Kandric Ho		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to conduct the required annual inspection. Upon arrival, LPA was greeted by staff member Kendrick Ho, who granted access to the facility. LPA explained the purpose of the visit.The facility is a one-story residence consisting of four client bedrooms, two bathrooms, and one staff bedroom. All client bedrooms were observed to contain the required furnishings, including beds with appropriate linens and blankets. Windows throughout the facility were screened. The backyard includes a shaded seating area.At the time of the visit, one staff member and one client were present at the facility. The facility has a total of three clients, with two currently attending day program. Both bathrooms were clean and free of debris or mildew. Faucets and toilets were functional, and the water temperature measured at 115.2 degrees Fahrenheit.Smoke detectors and carbon monoxide detectors were observed in all common areas and client bedrooms. All detectors were tested and found to be operational. Bath towels and personal hygiene supplies were adequately stocked. Common areas were clean, free of hazards, and all doorways were unobstructed.The facility’s first aid kit was complete and contained all required items, including bandages, tweezers, a thermometer, and scissors. The kitchen appliances were in working order. LPA observed an adequate supply of food on hand, including a two-day supply of perishable items and a seven-day supply of non-perishable goods, consistent with regulatory requirements. Sharps and knives were locked in a secured kitchen cabinet. Toxic substances were stored in a locked cabinet located in the garage, inaccessible to clients.PA reviewed two client files and two staff files. All reviewed files contained the required documentation. The facility Administrator’s certificate is current, with an expiration date of March 25, 2025.The fire extinguisher was fully charged and had been last inspected on March 14, 2025. The facility’s most recent fire drill was conducted on April 14, 2025. Fire drills are conducted quarterly by the Administrator.Based on the observations made during today’s inspection, no deficiencies were cited in accordance with Title 22, Division 6 of the California Code of Regulations.An exit interview was conducted, and a copy of this report was provided

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 2