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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881415
Report Date: 05/01/2023
Date Signed: 05/01/2023 04:05:09 PM


Document Has Been Signed on 05/01/2023 04:05 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ANGELICA'S HOME, INC.FACILITY NUMBER:
331881415
ADMINISTRATOR:OOSTING, ANGELICAFACILITY TYPE:
740
ADDRESS:31916 CORTE POSITASTELEPHONE:
(321) 432-8883
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 0DATE:
05/01/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Applicant, Kenneth OostingTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing visit. LPA met with Applicants Kenneth and Angelica Oosting who were informed of the purpose of the visit. The applicant is seeking an initial application. The population served is elderly ages 60 and over. The capacity will be for (6) residents. No pools or fire arms are being kept at the facility.

LPA conducted a walk through of the interior and exterior of the facility. The home is a one story with total amount of rooms amounts to (4) and (3) bathrooms . The fire clearance conducted by Riverside County Fire Department was approved for (5) non-ambulatory and (1) bedridden residents. LPA observed the residents bedrooms which had the appropriate furniture such as bed, dresser, closet space, light, and chair. The facility has first aid kit with required items. The facility kitchen was observed to be clean and posses equipment to conduct meal preparation for residents The kitchen had the appropriate food items for the capacity of the facility. LPA observed the bathrooms in the facility to have hand hygiene supplies. The facility possesses cleaning supplies to conduct regular cleaning of the facility. The smoke alarms and carbon monoxide detectors were found to be in operating condition. The dining room has enough seating for all residents with dining area. The outdoor space has enough seating to accommodate residents with a shaded areas. The hot water temperature was recorded at 107F, and the land line was observed to be operational. Kitchen knifes will be kept in designated area inaccessible to residents. The medications will be kept locked in hallway closet room.

An exit interview was conducted where this report was reviewed and provided to applicant, Kenneth Oostings.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
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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