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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002598
Report Date: 06/07/2023
Date Signed: 06/08/2023 09:48:29 AM

Document Has Been Signed on 06/08/2023 09:48 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Colleena Johnson, Administrator
Kendell Johnson, Licensee/Administrator		TIME COMPLETED:
04:30 PM
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On 6/7/2023 LPA Tryon visited the facility to do an annual visit. LPA met with Kendell Johnson and Coleena Johnson.
LPA toured the facility including common areas, kitchen, yard, bedrooms, bathrooms, hallways, garage, storage. The house is appropriately furnished, clean and in good condition.
Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable. The home has appropriate supplies of cleaners, self-care products, PPE, etc.
Smoke detectors and carbon monoxide detectors installed, fire extinguishers present and charged.

LPA reviewed the CARE Tool with staff. The home appears to be in general compliance with regulations at this time.

No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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