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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881293
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:24:58 PM


Document Has Been Signed on 03/30/2022 03:24 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, 744 P STREET, MS 9-14-8201
, CA 95814



FACILITY NAME:ANGELES HOME CAREFACILITY NUMBER:
331881293
ADMINISTRATOR:MATAMOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:32650 WESLEY STREETTELEPHONE:
(951) 226-8259
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:6CENSUS: 5DATE:
03/30/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Michelle MatamorosTIME COMPLETED:
03:24 PM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Change of ownership
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Michelle Matamoros
Interview Method: Telephone interview
On March 30, 2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Joshua MillerTELEPHONE: (916) 651-0571
LICENSING EVALUATOR NAME: Bethany HunterTELEPHONE: (916) 651-7901
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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