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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881293
Report Date: 06/02/2023
Date Signed: 06/02/2023 11:43:37 AM


Document Has Been Signed on 06/02/2023 11:43 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,
, CA



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: 6DATE:
06/02/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Staff, Jamie LuceroTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced collateral visit to the facility on 6/2/2023 at 9:06 a.m. Collateral visit was needed in order to conduct interviews and collect documents for a matter unrelated to the facility. LPA met with Staff, Jamie Lucero who was informed of the purpose of the visit. LPA spoke with the Administrator, Michelle Matamoros over the phone during the visit.

An exit interview was conducted where this report was reviewed and provided to Staff, Jamie Lucero.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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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