405850256-4-6-2022-29-AS-JOLN-CD8PG3-20220406111739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850256
Report Date: 04/06/2022
Date Signed: 04/06/2022 11:18:31 AM

Document Has Been Signed on 04/06/2022 11:18 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 HOME LLC		FACILITY NUMBER:	405850256
ADMINISTRATOR:	WON, YOUNG		FACILITY TYPE:	735
ADDRESS:	621 PALOMINO CIRCLE		TELEPHONE:	(805) 610-3676
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 4		CENSUS: 0	DATE:	04/06/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Young Won, Administrator		TIME COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Jeannette Olson conducted an announced pre-licensing visit. Applicant and Administrator Young Won took LPA on a plant tour of the inside and outside of the facility and the following is noted: Medications: There is a locked cupboard in the Kitchen for the medication. Physical Plant: The facility is a 5 bedroom, 2 bathroom home with a kitchen, dining room, living room, laundry room and garage. Facility is clean, sanitary and in good repair. Protective devices are in place. Indoor areas, outdoor porch, play area and backyard are free of obstructions. The facility does not have any pools or bodies of water. The facility does not store or allow firearms or ammunition to be stored at the facility. Any dangerous products/tools will be stored in locked garage, locked cupboards in the laundry room or kitchen. All windows screens are clean and in good repair. Facility temperature is between 68-85 degrees. Fireplace has a secured screen making it inaccessible to clients in care. Smoke and carbon monoxide detectors were tested and operating properly throughout the facility. Bedrooms: The facility has four resident bedrooms and one bath for single occupancy. Bedrooms have beds for each resident with mattress, mattress pads, box springs and pillows which are clean and in good repair. Mattresses and pillows are flame-retardant. The rooms have dressers and plenty of closet space for residents. The rooms are furnished with chairs and proper lighting with lamps are in each room for clients. Supplies: The facility has a sufficient supply of resident personal hygiene supplies, clean linens, towels and wash clothes. The supply of linens is sufficient for changing weekly or more if needed. Operational Requirements: The facility has a fire clearance, plan of operation, shaded outdoor area and bond for handling clients cash resources. The water in the kitchen was 114.8 degrees and the water in the clients bathroom was 117.5 degrees which meets regulation requirement. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME LLC	FACILITY NUMBER: 405850256
	VISIT DATE: 04/06/2022

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
26
27
28
29
30
31
32

Food Service: Dining room is near kitchen, Refrigerator and freezer are clean and large enough for the storage of at least two days of perishable food. Freezer is 0 degrees Fahrenheit and refrigerator was at 36 degrees which meets regulation requirements. A seven day supply of non-perishable food is present in the other facility that they will it move to this facility. A three day supply of perishables are present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. There is a sample menu with times for all meals and snacks.
Records: The facility has confidential storage for personnel and resident records, they will be kept on shelves in locked kitchen or office areas.
Administration: The facility has emergency plan and phone numbers posted, Residents rights, Facility visiting policy, Licensing Complaint Poster is posted in a prominent place at the facility. The facility has infection control signs on the front door and in the living room.
Activities: There is an outdoor space with a shaded areas and furnished for outdoor use. There is at least one common room available for residents and visitors.
Miscellaneous: The facility has a current first aid manual with a first aid kit and all required supplies are present. There is working equipment for laundry. There is space for clean linen storage and separate space for soiled linen. The facility has an operating telephone available for residents use. The facility has a fire extinguisher hanging on the wall between the kitchen and dining room with a receipt stating it was purchased on 3/25/22. Emergency lighting and supplies to include flashlights with batteries, emergency food supply and water is available for emergency use.

No citations issued on a pre-licensing visit.

Exit interview conducted, copy of report emailed to Applicant.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2