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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602552
Report Date: 08/24/2021
Date Signed: 08/24/2021 07:42:50 PM

Document Has Been Signed on 08/24/2021 07:42 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ANGELS HAVEN IIFACILITY NUMBER:
374602552
ADMINISTRATOR:FRENCH, CHRISTINEFACILITY TYPE:
735
ADDRESS:3949 BAJA VISTA DRIVETELEPHONE:
(760) 722-3955
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 6CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Francis Bautista, Facility ManagerTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Joel Bargamento, Caregiver. LPA met with Francis Bautista, Facility Manager and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Facility Manager Bautista conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures/ for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with House Manager Bautista. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Francis Bautista, Facility Manager, and Christine French, Licensee at the conclusion of the visit. LPA requested for Facility Manager Bautista to send LPA an electronic message reply confirming receipt of these documents.

LPA requested Facility Manager Bautista and Licensee French to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-D to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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