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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006228
Report Date: 02/16/2024
Date Signed: 02/16/2024 11:21:41 AM


Document Has Been Signed on 02/16/2024 11:21 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ANGEL COMFORT CARE 2FACILITY NUMBER:
306006228
ADMINISTRATOR:TEVES, ANGELINAFACILITY TYPE:
740
ADDRESS:1212 W ROWAN STTELEPHONE:
(562) 936-8063
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 3DATE:
02/16/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelina Teves - AdministratorTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility at 10:00 am for the purpose of conducting a Case Management Health and Safety Check. LPA was greeted and granted entry by Caregiver Marilyn Bustamante. LPA asked the Caregiver to call the Administrator to notify them that Licensing is at the facility. Caregiver called Administrator at 10:06 am.

LPA toured the facility. Based on review of the fire extinguisher service tags, LPA determined extinguishers have not been serviced since 12/08/2022. A deficiency is being issued on this day.

AD Angelina Teves arrived at the facility at approximately 10:30 am. LPA stated the purpose of the inspection. LPA requested and received copies of the following documents: Facility's Relocation Plan as stated on their Disaster Plan, a receipt for most recent payment to utility company and Register of Facility Residents. LPA verified via phone call to the utility company that the facility has a balance of $0.00.

LPA verified the facility phone number listed in the FAS profile is accurate. LPA documented the facility updated facility Mobile Number on an LIC812.

Based on today's inspection, one deficiency is being cited per Community Care Regulations. This report was reviewed with the Administrator and a copy of the report was provided.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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


Document Has Been Signed on 02/16/2024 11:21 AM - 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ANGEL COMFORT CARE 2
FACILITY NUMBER: 306006228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2024
Section Cited
CCR
80020(a)

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FIRE CLEARANCE: (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department. This requirement was not met as evidenced by:
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Administrator reach out to have the Fire Extinguishers serviced or purchase new Fire Extinguishers and submit proof to LPA via email by POC due date of 2/17/2024.
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Based on observation, the Administrator did not ensure the facility’s Fire Extinguisher was serviced annually, (last serviced on 12/8/2022), which poses an immediate health and safety risk to the persons in care.
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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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2