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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002598
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:30:12 PM

Document Has Been Signed on 06/28/2022 12:30 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ANGEL WINGS, INC. #2FACILITY NUMBER:
585002598
ADMINISTRATOR:JOHNSON, KENDELLFACILITY TYPE:
735
ADDRESS:5563 ROARING RAPIDS WAYTELEPHONE:
(530) 870-8652
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Colleena JohnsonTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 06/28/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Assistant Administrator Colleena Johnson and explained the purpose of the visit. Prior to initiating the annual inspection visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Administrator.

LPA and facility staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, a couple of resident bedrooms, common bathroom, laundry area, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time.

Multiple topics were discussed.

Facility is to update the following by July 15, 2022:
-LIC 500 facility personnel or a staff schedule
-LIC 308 Designation of Administrative Responsibility

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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