306006525-7-2-2024-22-AS-MTEA-D6SUMJ-20240702154224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006525
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:43:02 PM

Document Has Been Signed on 07/02/2024 03:43 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:	ABK ANGELS HOMECARE, INC.		FACILITY NUMBER:	306006525
ADMINISTRATOR:	TRUONG, BRENDA K.A		FACILITY TYPE:	740
ADDRESS:	10122 NORTHAMPTON AVE		TELEPHONE:	(714) 837-1823
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	6	CENSUS: 0	DATE:	07/02/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Brenda Truong		TIME COMPLETED:	04:00 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) Michael Tea made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Tea met with designated Administrators (ADs) Brenda Truong and Kristine Truong. An application to operate a Residential Care Facility for Elderly (RCFE) was received by our agency on January 31, 2024 for a total capacity of six; six non ambulatory and four maybe on hospice. Fire clearance was approved by a fire inspector from the Orange County Fire Authority on March 14, 2024. The facility is a one story home with five resident bedrooms, one of the five is a shared room, two bathrooms, a living room, a kitchen, a dining area, and an attached two car garage. All exiting doors had alarm notifications. There are two backyard exit gates on each side of the house that is self-latching and unlocked. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. There is a lovely garden area with plants and fruit trees. LPA observed both Administrator certificates, See Something, Say Something poster (PUB 475), Personal Rights, Ombudsman poster, Facility sketch and Emergency Disaster Plan in the facility mounted on the wall around the facility entryway. Fire extinguisher is located in the front entryway fully charged with an inspection date of June 25, 2024. Resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. All toxic chemicals, cleaning solutions, and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink. Medications will be stored in a locked cabinet in the living room. The first aid kit is also stored in the locked cabinets in the living room and has all the required elements. Staff and resident records will also be stored and locked in the cabinets in the living room. Reading materials and games were observed in the living room with a phone and computer station for residents can use. Continuation of Pre-licensing on LIC 809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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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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: ABK ANGELS HOMECARE, INC.	FACILITY NUMBER: 306006525
	VISIT DATE: 07/02/2024

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A supply of seven-day of perishable and non-perishable food was observed and will be maintained on hand. Smoke detectors and carbon monoxide detectors tested operational. Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational. There are cameras placed in the common areas of the facility without audio for the safety of residents in care. Hot water temperatures in the bathrooms measured between 116.7 and 112.6 degrees F. Emergency food and water and additional supplies were observed to be well stocked in the garage.

The facility is ready to be licensed. LPA conducted the Component Three Orientation with ADs. ADs was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

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