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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410506298
Report Date: 01/14/2025
Date Signed: 01/14/2025 10:24:37 AM

Document Has Been Signed on 01/14/2025 10:24 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ANGELA'S REST HOME IFACILITY NUMBER:
410506298
ADMINISTRATOR/
DIRECTOR:		ANA MANE AREVALOFACILITY TYPE:
740
ADDRESS:1816 LOUVAINE DRIVETELEPHONE:
(650) 992-1690
CITY:COLMASTATE: CAZIP CODE:
94015
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
01/14/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Ana Marie ArevaloTIME VISIT/
INSPECTION COMPLETED:
10:37 AM
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On January 14, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management health and safety visit in response to Licensee, Angela Carillo passing away. LPA met with Administrator, Ana Marie Arevalo and explained the person.

LPA toured the facility, no bodies of water or fire safety hazards observed. LPA toured the living room, dining room, kitchen, common areas, resident rooms and bathrooms. Facility was observed clean and odor-free. LPA observed two full bathrooms equipped with grab bars and non-skid mats. One staff rooms was observed. LPA observed four resident rooms; 3 of which are private and one of which is a shared room. All resident rooms were observed to have required furnishings. Extra linen was observed present. Four staff members were present at the facility providing care and supervision to two residents.

LPA toured kitchen and observed sufficient food supply. Medications, toxins, sharps and chemicals were observed to be locked and inaccessible to residents. First-aid kit is complete. Hot water was observed to be measuring within regulatory requirements. Lighting is sufficient for comfort and a comfortable temperature is maintained.

No citations issued during the visit. Report is reviewed with Administrator, Ana Marie Arevalo and a copy is provided.

No deficiency cited today. This report is reviewed and discussed with the administrator. A copy is provided.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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