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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003006
Report Date: 09/01/2023
Date Signed: 09/05/2023 09:34:58 AM

Document Has Been Signed on 09/05/2023 09:34 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FOUR ANGELS CARE HOMEFACILITY NUMBER:
345003006
ADMINISTRATOR:MAMARIL, THELMAFACILITY TYPE:
735
ADDRESS:5616 RIDGEPOINT DR.TELEPHONE:
(408) 477-0978
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 0DATE:
09/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Thelma Mamaril and Nino DomalantaTIME COMPLETED:
04:00 PM
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On September 1, 2023 LPA Tryon visited the facility to do a pre-licensing visit. LPA met with applicants Thelma Mamaril and Nino Domalanta.

LPA toured the house including kitchen, living room, visiting room, bedrooms, hallways, bathrooms, garage, laundry area, yard. The facility is clean, nicely furnished and pleasant. The bedrooms have appropriate furniture and plenty of space. The backyard is fenced and has space for activities and shady areas. There is a hot tub in the back yard with a cover, but the applicants plan to dispose of the hot tub as soon as possible. The home will notify CCL as soon as the hot tub is gone.

The home has installed smoke detectors and carbon monoxide detectors, has charged fire extinguisher that was recently checked/serviced.

There is locked storage for medications, knives/potentially hazardous items, etc. The home has plenty of dishes/cups, pots and pans, utensils, kitchen appliances, etc. The home has plenty of food supplies present including 2 days perishable and 7 days non-perishable supplies.

LPA reviewed the CARE Tool for pre-licensing with the applicants.

LPA also reviewed the Adult Residential Orientation Part III with the applicants. Applicants have now completed Orientation Part III.

At this time, the facility appears to be in substantial compliance with regulations. There is a hot tub in the yard, but it has a tight-fitting cover with a LOCK and the applicants plan to dispose of the hot tub.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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