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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850256
Report Date: 03/25/2024
Date Signed: 03/25/2024 09:32:02 AM

Document Has Been Signed on 03/25/2024 09:32 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:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee, Jusik KimTIME COMPLETED:
10:18 AM
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At 8:00am on 03/25/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Administrator Junsik Kim, announced who he is and the reason for the visit.

Administrator and LPA conducted a physical walking tour of the facility. LPA noted that this is 5 bedroom and 2 bathroom facility. Each client has their own room and all share one bathroom. The master bedroom is a staff room and has an on suite bathroom for staff. The outside has seating and a pergola for shade. There are working smoke detectors throughout the facility and a working carbon monoxide detector in the lving room/dining room area. There is a working fire extinguisher in the dining room. Medication is locked and stored in a locked cabinet in the kitchen. First Aide kit is located on the stand in the dining room where the PPE is located. LPA noted that all client bedrooms have all regulated furniture, linin, and bedding. LPA noted that there is at lease 2 days of perishable foods and at least 7 days of non perishable foods on hand for 4 clients and staff. LPA noted that the facility is clean and in good repair. LPA observed required postings on the wall in above the dinning room desk. LPA noted that the facility is clean and in good repair. LPA noted that the facility is operating within the regulation of their fire clearance. LPA noted that all walkways, halls, and door ways are free and clear of debris and obstacles. LPA noted that staff and clients files were reviewed and had no observe issues. LPA conducted a sample review of the centrally stored medication record (CSMR) and noted no observed issues. LPA noted that there were no technical, violations, or citations issued as a result of the facility physical walk through inspection.

Administrator and LPA conducted a full review of the facilities annual control tools modules and noted that there were no technical, violations, or citations issued as a result of the annual facility inspection, full control tools modules. LPA note that the full facility annual inspection that there were no technical, violations, or citations issued.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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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