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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005476
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:33:06 PM

Document Has Been Signed on 01/16/2025 04:33 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 CARE GUEST HOMEFACILITY NUMBER:
306005476
ADMINISTRATOR/
DIRECTOR:		JABONERO, JANICEFACILITY TYPE:
740
ADDRESS:10212 MALINDA LANETELEPHONE:
(714) 244-5885
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:36 PM
MET WITH:Ruby Cuz, Janice JaboneroTIME VISIT/
INSPECTION COMPLETED:
04:47 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Licensee (LE) Ruby Cuz and discussed the purpose of the inspection. Administrator (AD) Janice Jabonero arrived during the inspection.
LPA reviewed Infection Control requirements. At about 2:00PM, LPA and LE conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 2-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 6 residents present at the facility. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 and 113 degrees F the two resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 3:00PM, LPA reviewed 6 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 6 residents. Facility does not handle resident money.
During the inspection, LPA and LE observed the following: based on observation, the facility's only side exit which is to be used as an emergency exit was dead-bolted shut.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
Armando J LuceroTELEPHONE: (714) 703-2840
Sean HaddadTELEPHONE: (714) 335-7094
DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 01/16/2025 04:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ANGELS CARE GUEST HOME
FACILITY NUMBER: 306005476

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility's only side exit which is to be used as an emergency exit was dead-bolted shut, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 01/17/2025
Plan of Correction
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During the inspection, licensee removed the dead bolt and LPA confirmed. Licensee stated they will conduct staff training on not locking exit doors and submit proof to LPA by 1/23/25.
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.
Armando J LuceroTELEPHONE: (714) 703-2840
Sean HaddadTELEPHONE: (714) 335-7094

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025

LIC809 (FAS) - (06/04)
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