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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003008
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:54:49 AM


Document Has Been Signed on 08/10/2023 11:54 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:LOVING ANGELS CAREHOME 2FACILITY NUMBER:
345003008
ADMINISTRATOR:MUNGCAL, MIRASOLFACILITY TYPE:
740
ADDRESS:4722 HACKBERRY LANETELEPHONE:
(916) 350-4749
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
08/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Mirasol Mungcal, Licensee/AdministratorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Angela Hood met with the Administrator, Mirasol Mungcal, to conduct a Pre- Licensing visit for a change of ownership. There are currently 5 residents with 1 additional resident moving in 8/11/23. Administrator has a current certificate #6048112740 with an expiration date of 4/24/2024.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and three (3) bathrooms for resident use. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 112.3 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care.

LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed (2) resident files and two (2) staff files.

Pre-licensing passed and LPA waived Component III. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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