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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003611
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:36:41 PM

Document Has Been Signed on 08/18/2023 02:36 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PRECIOUS ANGELS CAREFACILITY NUMBER:
347003611
ADMINISTRATOR:ALEJO, GLORIAFACILITY TYPE:
740
ADDRESS:8983 RICHBOROUGH WAYTELEPHONE:
(916) 549-2724
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 1DATE:
08/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Verly MendozaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to the facility to conduct a case management visit. LPA Valerio was informed that residents were moving out from the facility and the last resident would be gone by COB 08/18/2023.

LPA Valerio and LPM Richardson was met by facility staff Verly Mendoza. Staff stated there is only 1 resident in care. The other two residents moved out on 08/15/23 and 08/17/23. The last resident is to move out at 2:00 PM on 08/18/23. LPA and LPM contacted Licensee Antonette Tin via cell phone and requested her to come to the facility. Licensee Antonette Tin arrived to the facility at 02:00 PM. According to Licensee, the two residents were not told to move out and they left for personal reasons. Personal reasons were not disclosed to CCL or Licensee. At the end of the visit, 0 residents were observed to be in care.

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8 - no deficiencies are being cited. An exit interview was held with Licensee, and copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
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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