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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601276
Report Date: 04/23/2024
Date Signed: 04/24/2024 11:05:28 AM


Document Has Been Signed on 04/24/2024 11:05 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
SAN DIEGO RO, 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: 5DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Licensee Cathy McEvoyTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced visit to the facility to conduct the required annual licensing inspection. LPA was granted entry into the facility by Licensee McEvoy, identified herself, and stated the purpose of today’s visit, to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

During today's visit there were five (5) residents and three (3) staff present. LPA Correia began a general overall inspection. All Resident rooms were equipped with the required furnishings. Resident bathrooms were observed to be sanitary and equipped with the required supplies. Grab bars and non-skid flooring were present for showers used by residents in care. Lighting was maintained in hallways and passages to resident bathrooms. Facility has a pond that is gated and secure and inaccessible to residents in care. LPA Correia observed smoke alarms, and carbon monoxide detectors throughout the facility that were in operable condition. Per Licensee there are no weapons and/or ammunition housed in the facility.

An overall inspection of the facility began today. However, due to time constraints LPA was unable to complete the visit and will return later to conduct the remaining portion of this inspection.



No deficiencies were cited during today's visit. This report was discussed with Licensee McEvoy. A copy of the report and License Rights (01/2016) will be provided at the conclusion of the visit, and signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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Document is an Amendment of Original Document on 04/25/2024 12:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2024
Section Cited
CCR
87205(b)

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ACCOUNTABILITY OF LICENSEE GOVERNING BODY - If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by:

This is an amended version of the original report dated 4/23/24,
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Licensee will be contacting her attorney to remedy the issue and will provide the department with proof of correction by the POC due date.


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On 03/04/2019 at 7:58am, LPA ran a business search on entity number C3802815 for Angel's Guest Home. The entity number returned as FTB Suspended. This poses a potential safety risk to residents in care.

This is an amended version of the original report dated 4/23/24,
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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