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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850256
Report Date: 02/18/2023
Date Signed: 02/18/2023 10:35:53 AM

Document Has Been Signed on 02/18/2023 10:35 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 LLCFACILITY NUMBER:
405850256
ADMINISTRATOR:STEPHANIE SALKEFACILITY TYPE:
735
ADDRESS:621 PALOMINO CIRCLETELEPHONE:
(805) 610-3676
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 4DATE:
02/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:51 AM
MET WITH:Stephanie Salke / AdministratorTIME COMPLETED:
10:35 AM
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 At 8:00am on 02/18/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual, infection control visit. LPA was screened at the door by morning staff (S1). S1 was not wearing any mask or face coverings, S1 did not have any exemptions for face coverings. S1 contacted Licensee by phone. At 8:53am Administrator Junsik Kim arrived at the facility. At 9:01am Administrator Stephanie Salke arrived at the facility. LPA noted that S1 was not showing to be cleared on the staff roster, however Administrator provided paperwork for S1 showing cleared with SID number. Administrator Salke associated S1 on Guardian during annual infection control visit. LPA and Administrator discussed client age requirements for Adult Residential Facilities (ARF) and Residential Care Facilities for Elderly (RCFE).

Administrators and LPA conducted the annual infection control module of the annual inspection. LPA noted one technical Advisory for staff not wearing mask. No other violations, technical, or citations were noted from the infection control module of the annual inspection.

Administrators and LPA conducted a cursory walk through tour of the facility. The facility has four bedrooms and two bathrooms. Two bedrooms are single occupancy and one bedroom is double client occupancy. The upstairs bedroom and bathroom is a live-in staff bedroom and bathroom. LPA observed liquid soap and paper towels in the bathrooms. LPA observed at least a 30 day supply of PPE stored throughout the facility. LPA tested and noted the facility water temperature is within regulation parameters of 105*-120* (f). LPA noted that fire alarms and carbon monoxide detectors were tested and working. The fire extinguisher was currently tagged and in the green reading. Medications are in a locked cabinet in the hallway. The facility is clean and in good repair. The facility is free of any visible hazards and all exits are free and clear of obstruction. LPA noted that no violations, technical, or citations were issued at this time as a result of the cursory walk through tour of the facility. One technical advisory was issued during this annual, infection control inspection.
Exit interview, report singed, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2023
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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