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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881145
Report Date: 06/01/2022
Date Signed: 06/01/2022 12:55:54 PM


Document Has Been Signed on 06/01/2022 12:55 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, 1650 SPRUCE ST STE 200 MS29-27
, 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: 6DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Milagros Azaula - LicenseeTIME COMPLETED:
12:57 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with care staff who asked LPA to enter from the back door for a rapid Covid-19 test prior to entry. Licensee conducted the test and granted entry to LPA and Licensee verified there are no active and/or suspected Covid-19 cases in the home.

During today's visit, LPA Bueno toured the outside and LPA and Licensee toured the facility inside. LPA interviewed Licensee regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms postings and personal rights postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify their physician and emergency personnel in the event resident presents with COVID-19 symptoms.

LPA Bueno observed that the facility appears to be meeting operational requirements. LPA observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with sufficient food supplies. All areas of the facility, including resident bedroom and bathrooms, appeared to have appropriate furnishings, are clean, and in good repair. LPA Bueno observed no apparent health and safety risks at the time of visit.

Based on interviews and observations, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and provided to Milagros Azaula at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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