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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003006
Report Date: 08/08/2024
Date Signed: 08/08/2024 11:59:45 AM

Document Has Been Signed on 08/08/2024 11:59 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/
DIRECTOR:		MAMARIL, THELMAFACILITY TYPE:
735
ADDRESS:5616 RIDGEPOINT DR.TELEPHONE:
(408) 477-0978
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 0DATE:
08/08/2024
TYPE OF VISIT:Post LicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Thelma Mamaril and Nino DomalantaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct an annual required and post licensing visit. LPA met with Administrators Thelma Mamaril and Nino Domalanta and explained the purpose of the visit.

For more information on the post licensing visit, please see LIC809 for Required - 1 Year dated 08/08/24.

No deficiencies cited for the post licensing visit.

Exit interview conducted a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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