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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701044
Report Date: 05/13/2021
Date Signed: 05/17/2021 11:48:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ANGEL'S CARING HANDFACILITY NUMBER:
502701044
ADMINISTRATOR:ANTONIO, MA TABITHAFACILITY TYPE:
740
ADDRESS:3709 COYE OAK DRTELEPHONE:
(209) 312-9880
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 6DATE:
05/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ma Tabitha AntonioTIME COMPLETED:
03:00 PM
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LPA Garcia and LPA Johnson, conducted this announced prelicensing visit. LPA toured with Ma Tabitha Antonio. This facility has a fire clearance for six non-ambulatory and six total.

This facility has four private and two shared resident rooms. There is staff room for sleeping so this facility is required to have awake night staff. There are two private residents room and two shared rooms to the right of the main entrance. All resident rooms have an exit to the outside. There is a common bathroom accessible to three rooms. There is a private bathroom attached to one of the double occupancy room. From the main entrance is an open entry welcome area , to the right of the main entrance is the first door that is the entrance to private room for Administrator. The are after the room to the right is the private room for staff. To the left of the open entry area is the dinning room, kitchen, and common area. There is a bathroom located next to common room that leads to the garage.
Staff and client files will be in locked closet area in dining room, centralized. All cabinets/ closets have keyed locks. The backyard was inspected and there is one gate on south side of the facility. The kitchen was inspected. There is a locked cabinet in kitchen for sharps. There is cabinet that stores the medications. Refrigerated medications will be stored in clear lock box in main fridge. Both front and backyards are well maintained. There are audio alerts on all exits.

Component III orientation completed and certificate posted. The Administrator has 1 year of licensing experience . LPA is going to submit this report to the applications specialist for review.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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