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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850094
Report Date: 10/24/2024
Date Signed: 10/24/2024 09:06:52 AM

Document Has Been Signed on 10/24/2024 09:06 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/
DIRECTOR:		JUNSIK KIMFACILITY TYPE:
735
ADDRESS:2648 VINEYARD CIRCLETELEPHONE:
(805) 610-3676
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 2DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Licnesee, Young WonTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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 At 7:45am on 10/24/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee, Young Won announced who he was and the reason for the visit being the annual facility inspection. LPA noted that the 2 Clients in care a recent transfers from a closing facility and stated they are very happy in their new placement. LPA noted that 2 clients were clothed, fed, and medications were administered before 7:45am on the day of this visit.

Licensee and LPA conducted a physical tour of the facility, LPA noted that the facility is a 5-bedroom 2-bathroom facility, 4 of the bedrooms are client rooms and 1 bathroom for clients. The 5th bedroom is for live-in staff with on suite bathroom. LPA noted that the facility is clean and in good repair. All exits are free and clear of obstructions, The carbon monoxide detector and smoke alarms are working. The first aide kit is located in the closet in the living room hallway and the medication closet is locked and located in the kitchen pantry. LPA noted that the client’s rooms have all furnishings and linins supplies required by regulations. LPA observed at least 2 days of perishable foods and at least 7 of non-perishable foods on hand at the facility. LPA conducted a review of Centrally Stored Medication log and found no issues. LPA noted that all postings and Emergency Disaster plan was posted and/or in binders at the front entrance to the facility. LPA noted that the back yard has seating and shade for clients. LPA reviewed Emergency Disaster Plan, Infection control Plan, Client files, Staff files, and Medication Records.

Licensee and LPA conducted all modules of the annual control tools. LPA noted that no violations or citations were issued as a result of the full annual inspection and full care tools modules. At this time there are no citations issued on this annual facility inspection. Interviews of 1 of 1 staff and 2 of 2 clients completed.

Exit interview, report read, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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