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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850381
Report Date: 05/21/2024
Date Signed: 05/21/2024 11:32:44 AM

Document Has Been Signed on 05/21/2024 11:32 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:
405850381
ADMINISTRATOR/
DIRECTOR:		WON, YOUNGFACILITY TYPE:
735
ADDRESS:1486 COUNTRY CLUB DRTELEPHONE:
(805) 286-4239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 0DATE:
05/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator - Young WonTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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 At 9:00am on 05/21/2024, Licensing Program Analyst (LPA) Jeffries arrived at the pre planed appointment time. LPA announced who he is and the reason for the visit.

At 9:05am, Licensee/Administrator, and LPA conducted a physical tour of the facility. LPA observed facility Plan of Operations, Emergency Disaster Plan, Infection control plan and all necessary posting on the facility wall above the desk in living room. This is a 2 story, 4 bedroom 3 bathroom, with living room and open kitchen area with dining table between the kitchen and living room, the first floor is 2 bedrooms for double client occupancy, and a shared bathroom and the 3rd bedroom is a live-in staff bedroom with on suite bathroom, and the upstairs is staff/Licensee occupancy only. There is a backyard for clients and visitors to be outside with table and built-in pergola for shade. All Client rooms are furnished with proper light, furniture, beds and linins to meet regulation requirements. All clients share the single bathroom. Bathroom had paper towels dispenser and is equipped with liquid soap, non-skid shower mat on shower floor. Water temperature in the facility was measure at 109*(f). LPA observed smoke detector throughout the facility and carbon monoxide detectors in working condition. LPA observed fire clearance (SD850) dated 08/28/2024 for 4 ambulatory clients. LPA observe a working fire extinguisher and a complete first aide kit on hand at the facility. LPA observed emergency food and water supply in the garage. LPA observed chemicals and hazards to be locked and stored in cabinet. LPA did not find any other violations during the facility tour.

At 9:50am Licensee/Administrator and LPA conducted a full review and reading of the pre licensing care tools modules. During the review, all applicable questions were affirmed with compliance by observation and documented review. There were no deficiencies discovered during the control tools module read and review.
Licensee and LPA conducted a full review of the Component III Orientation on 05/09/2024, for review as this licensee has four other currently licensed facilities.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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