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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850404
Report Date: 09/09/2024
Date Signed: 09/10/2024 09:48:00 AM

Document Has Been Signed on 09/10/2024 09:48 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:
405850404
ADMINISTRATOR/
DIRECTOR:
KIM, JUNSIKFACILITY TYPE:
735
ADDRESS:189 RIVERBANK LANETELEPHONE:
(805) 610-3676
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 4CENSUS: 3DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Young WonTIME VISIT/
INSPECTION COMPLETED:
11:43 AM
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At 9:00am on 09/09/2024, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee Young Won and New Administrator Chong Kim.
At 9:10am Licensee, Administrator and LPA conducted a full review and reading of the annual care tools modules. During the review, all applicable questions were affirmed with compliance by observation and documented review. There were no violations discovered during the control tools module read and review.
At 10:15am, Licensee, Administrator, and LPA conducted a physical tour of the facility. LPA observed Emergency Disaster Plan, Infection control plan and all necessary posting on the facility wall near the entrance and Plan of Operations was printed and in a binder. This is a 5 bedroom 2 bathroom, living room and open kitchen area. There is ample backyard for clients and visitors to be outside with table and umbrella for shade. Bedrooms 1, 2, 3, and 4 are all single client rooms with proper light, furniture, beds and linins to meet regulation requirements. The 5th bedroom is a staff bedroom with on-suite bathroom. Clients share the single bathroom. Bathroom had paper towels dispenser and is equipped with liquid soap, non-skid stickers on shower floor. Water temperature in the facility was measure within the regulation requirement. LPA tested working smoke detector throughout the facility and carbon monoxide detector is in working condition. LPA observe a working fire extinguisher and a complete first aide kit on hand at the facility. LPA observed a emergency food and water supply in the garage. LPA observed chemicals and hazards to be locked and stored in laundry room, closet adjacent to laundry room and under kitchen sink. LPA noted that all client bedrooms had appropriate furnishings and linin per regulations. LPA noted that the facility had at least 2 days of perishable foods and at least 7 days of non-perishable foods on hand at the facility. LPA noted that the facility is clean and in good repair and noted not violations or citation on the physical facility walk through. LPA noted that there are no citations on this full annual inspection. LPA noted that all clients were at day program during the inspection and two staff interviews were conducted.
Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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