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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801215
Report Date: 04/18/2024
Date Signed: 04/18/2024 05:11:45 PM


Document Has Been Signed on 04/18/2024 05:11 PM - 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:ANGELS IIFACILITY NUMBER:
565801215
ADMINISTRATOR:JOANN TRUPIANOFACILITY TYPE:
740
ADDRESS:2375 MCDONALD COURTTELEPHONE:
(805) 404-5201
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
04/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:49 PM
MET WITH:Honorata Perla AvestroTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management - Deficiencies visit due to deficiencies observed during the investigation related to complaint control 29-AS-20230504133547.

Licensee/Administrator did not comply with reporting requirements when resident #1 (R1) eloped from facility on 01/17/2023.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency were cited (refer to LIC 809-D):

Exit interview conducted. Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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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Document Has Been Signed on 04/18/2024 05:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANGELS II
FACILITY NUMBER: 565801215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2024
Section Cited
CCR
87211(a)

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 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence..
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Licensee will submit a plan how they will ensure reporting requirements are met. Submit to CCL by due date
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This requirement was not met as evidenced by: Based on records review, R1 eloped from the facility on 01/17/2023, however this incident was not reported to CCL timely, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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