<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850094
Report Date: 10/08/2022
Date Signed: 10/08/2022 10:54:07 AM

Document Has Been Signed on 10/08/2022 10:54 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANGEL'S GROUP HOMEFACILITY NUMBER:
405850094
ADMINISTRATOR:JUNSIK KIMFACILITY TYPE:
735
ADDRESS:2648 VINEYARD CIRCLETELEPHONE:
(805) 610-3676
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 4DATE:
10/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator / Stephnie Salke / Licenesee/ Young WonTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 9:15am on 10/09/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct and annual infection control inspection. LPA met with Debbie Pineda (S1) house lead staff and informed S1 who he was and the reason for the visit. S1 called Administrator Stephanie Salke and Licnesee Young Won to come to the facility for the inspection.
At 10:42am Administrator, S1 and LPA conducted a cursory tour of the facility. The facility is 5 bedroom 2 bathroom, kitchen, living room, dinning area, and laundry room. Four of the rooms are single occupancy by the clients the fifth bedroom is occupied by S1 and daughter of S1 (under 18 years of age.). There is an outside backyard with seating and umbrella for clients to use. Medications are locked in a cabinet in the kitchen next to the refrigerator, chemicals are locked in the laundry room. Client and staff files are located in a locked filing cabinet in the dining area. LPA observed fire detectors working and tested the carbon monoxide detector to be working. LPA observed at least 2 days of perishable and at lease 7 days of nonperishable foods on hand at the facility. LPA noted that water temperature was within regulation guidelines (95-120*f). LPA noted that the clients rooms all had appropriate linin and storage and lights were working. LPA noted that the over all condition of the facility was clean and well kept. LPA did not observe any hazards during this cursory walk through inspection.

S1, Administrator and Licensee conducted the infection control portion of the annual visit. LPA noted that there were no violations of deficiencies stated on the infection control portion of the annual inspection. At this time there are no deficiencies cited.

Exit interview, report singed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1