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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601276
Report Date: 03/17/2021
Date Signed: 03/18/2021 09:04:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ANGEL'S GUEST HOME #1FACILITY NUMBER:
374601276
ADMINISTRATOR:JENKINS, PATRICIAFACILITY TYPE:
740
ADDRESS:9208 BELLAGIO RDTELEPHONE:
(619) 258-2013
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 4DATE:
03/17/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Catherine McEvoy, Stephanie MercadoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Paul Petersen conducted a case management site inspection for this facility beginning at 1:00 PM. LPA met with licensee, Catherine McEvoy, and facility administrator, Stephanie Mercado, via telephone and tele-video (Facetime). The facility census is four.

LPA toured the facility via tele-video placing emphasis on COVID 19 safety precautions and facility readiness. The facility has postings at the front entry, health screening items (including thermometer, hand sanitizer, masks and log) at the front entry. Per administrator all individuals who enter the facility are health screened prior to entry including staff and visitors. LPA inspected facility PPE supplies including gloves, gowns, masks and N95 masks. LPA will arrange for a supply of medical grade N95 masks to be organized for this facility. LPA and administrator reviewed COVID 19 safety guidelines including social distancing, mask wearing and safe isolation of COVID positive residents.

A copy of this report was provided to administrator via email. The report is to remain in the facility records for a period of three years from today's date.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Paul PetersonTELEPHONE: (510) 622-2612
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021
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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