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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 02/06/2023
Date Signed: 02/06/2023 09:27:05 AM


Document Has Been Signed on 02/06/2023 09:27 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ANGELA'S CARE HOMEFACILITY NUMBER:
331880544
ADMINISTRATOR:ANGELA ZHANGFACILITY TYPE:
740
ADDRESS:13247 SUNBIRD DRTELEPHONE:
(951) 653-0652
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 5DATE:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:ADMINISTRATOR, ANGELA ZHANG.TIME COMPLETED:
09:30 AM
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On February 6, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control.

LPA Mixson met with Administrator introduced self and stated the purpose of the visit.

Present in the facility were two caregivers, and five residents. There are currently no positive cases of COVID-19 within the facility. All residents and staff are fully vaccinated and boosted.

LPA Mixson toured the facility with Administrator and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. Administrator paid annual fees today during this visit.

LPA Mixson later discussed infection control practices and procedures with Administrator.
An exit interview was conducted and a copy of this report was given to Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
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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