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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424393
Report Date: 02/07/2022
Date Signed: 02/07/2022 10:27:11 AM

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:MIKE'S ANGELS LLCFACILITY NUMBER:
336424393
ADMINISTRATOR:MARTINEZ, LORENAFACILITY TYPE:
740
ADDRESS:318 SANDALWOOD DRTELEPHONE:
(909) 795-0163
CITY:CALIMESASTATE: CAZIP CODE:
92320
CAPACITY:6CENSUS: 2DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:April Luckett, CaregiverTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Goldenberg made an announced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA was met at the door by Caregiver April Luckett and granted entry into the home. She is wearing a mask. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening will occur. The staff are temperature screening visitors upon entry into the facility. LPA was later met by Lorena Martinez, Administrator

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit. LPA observed that two (2) out of two (2) fire extinguishers had service tags dated 2016.

Based on observations made during today’s inspection, the following deficiency is being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative along with appeal rights. See LIC 809, LIC 809D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIKE'S ANGELS LLC
FACILITY NUMBER: 336424393
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
All facilities shall maintain a fire clearance approved by...

This requirement is not met as evidenced by: Tag on fire extinguisher last service date is noted to be 2016.
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 2 out of 2 fire extinguishers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2022
Plan of Correction
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Licensee to replace or have all fire extinguishers serviced within 24 hours. Proof of correction to be provided.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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