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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804151
Report Date: 04/04/2023
Date Signed: 04/04/2023 10:35:58 AM


Document Has Been Signed on 04/04/2023 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ANGIE'S ADULT CAREFACILITY NUMBER:
486804151
ADMINISTRATOR:MAMSAANG, ANGELITA CFACILITY TYPE:
735
ADDRESS:401 DONEGAL DR.TELEPHONE:
(707) 631-2999
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 0DATE:
04/04/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Angie Mamsaang, Licensee ApplicantTIME COMPLETED:
10:45 AM
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On 4/4/2023 Licensing Program Analyst (LPA) Dominic Tobola arrived to this facility for the purpose of completing a pre-licensing evaluation due to a change of location. LPA was greeted by Licensee Applicant, Angie Mamsaang and conducted a tour of the facility. The facility is a 6 bedroom, 4 bathroom, single story house with a granted fire clearance for 6 ambulatory clients. LPA toured the entire premise which was found to be clean and orderly. Fire extinguishers were found throughout the facility and last charged on 12/8/2022. Smoke detectors and monoxide detectors which were all tested and found to be in working order. Medications, facility files and emergency supplies are stored in a secured closet located in the hallway. Toxins and cleaning supplies are secured in a locked storage shed. Sharps and knives are also found to be secured in the kitchen.

LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 2 clients in process of transfer. Licensee will be purchasing additional food items upon client admissions. Additional linen supplies were found in cabinets located in the hallway and hygiene products for clients are located in each individual bathroom and upon request.

Beds were made with appropriate linens. Furniture is appeared safe and adequate. Hot water temperature was measured at 108.9 and 110.0 degrees F which is within regulation between 105 degrees F and 120 degrees F. LPA observed a slight crack on window located in client bedroom #6. Technical Assistance issued, Licensee Applicant agrees to submit photo proof of repairs to CCLD prior to admitting clients.

Emergency exits along the both sides of the facility have appropriate hardware and found to be unobstructed. Licensee has an updated liability insurance and will submit a copy to CCLD. Component III orientation was conducted with the Licensee Applicant.

The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided to the Licensee.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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