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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881044
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:28:24 PM

Document Has Been Signed on 01/16/2025 01:28 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGELVIEW CARE HOMES, INC. @ SAMANTHAFACILITY NUMBER:
331881044
ADMINISTRATOR/
DIRECTOR:
EMBALSADO, MAY BOCOFACILITY TYPE:
735
ADDRESS:23099 SAMANTHA PLACETELEPHONE:
(951) 780-4990
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 3DATE:
01/16/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:May Embalsado- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to conduct a case management visit for Client 1 (C1)’s death. LPA conducted a health and safety check and met Program Administrator, May Embalsado and explained the purpose of today’s visit. At the time of the visit, there was 3 (three) clients at the facility and 2 (two) staff members present at the time of the visit. Administrator May Embalsado arrived tot he facility shortly after.

During the LPA’s visit, LPA reviewed, requested, and obtained copies of pertinent documentation, conducted an interview with Administrator regarding C1’s death on 01/13/25. LPA interviewed to obtained further information regarding the death of C1 and the events that led up to C1’s death. According to Administrator, the cause of death was Multiple Organ Failure; however, Hospital documentation and Death Certificate is pending at this time. Administrator verbalized that she will be emailing LPA the Death Certificate when it becomes available.

No deficiencies were cited during this visit, as there were no health and safety concerns observed during today's visit.

An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list) were provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: 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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