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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336406709
Report Date: 11/28/2022
Date Signed: 11/28/2022 03:53:20 PM

Document Has Been Signed on 11/28/2022 03:53 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:ANGELVIEW CARE HOMES INC. @ RANCHO BAJAFACILITY NUMBER:
336406709
ADMINISTRATOR:F.AUMENTADO/M.BOCOFACILITY TYPE:
735
ADDRESS:27802 RANCHO BAJATELEPHONE:
(951) 485-7079
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 6CENSUS: 5DATE:
11/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Mae EmbalsadoTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a case management on a recent death at the facility. LPA met with Administrator, Mae Embalsado. who was informed of the purpose of the visit.

LPA requested the file for R1 and a summary of events leading the residents death. It was determined that the facility completde the reporting requirements by verbal incident report to the LPA assigned followed by a written incident report to the regional office. The administrator was advised on documents that would need to be sent to the LPA as they become available. LPA reviewed the Guardian roster and verified all staff have been fingerprint cleared.

No deficiencies were issued at the time of the visit.

An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Mae Embalsado.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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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