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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881145
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:27:36 PM

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:MILEY'S ANGEL HOME CARE, LLCFACILITY NUMBER:
361881145
ADMINISTRATOR:AZAULA, MILAGROSFACILITY TYPE:
740
ADDRESS:16510 GALA AVETELEPHONE:
(909) 428-1824
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: 4DATE:
08/20/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Giovanni AzaulaTIME COMPLETED:
03:30 PM
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LPA Javier Prieto arrived to the facility to conduct a post licensing inspection and to verify facility license status and confirm facility name under the address 16510 Gala Ave, Fontana. Miley's was licensed for six non-ambulatory clients with a hospice waiver of 6 and licensed on 06/21/21. There are 4 clients at the facility during time of visit. Facility is follow COVID procedures with proper postings. LPA spoke with licensee Milagros Azaula and met with staff Giovanni Azaula. An exit interview was conducted. Giovanni signed this report along with LPA Prieto and a copy was left with the facility.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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