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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002598
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:58:47 AM

Document Has Been Signed on 06/20/2024 11:58 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ANGEL WINGS, INC. #2FACILITY NUMBER:
585002598
ADMINISTRATOR/
DIRECTOR:
JOHNSON, KENDELLFACILITY TYPE:
735
ADDRESS:5563 ROARING RAPIDS WAYTELEPHONE:
(530) 870-8652
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 4CENSUS: 4DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:22 AM
MET WITH:Kendell JohnsonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Kendell Johnson.

This facility has a fire clearance for three ambulatory and one non-ambulatory residents This facility has four residents. There are four resident rooms and one staff room. There is one full common bathroom and one bathroom in the staff room. There are locked cabinets for cleaning products and medications.

No health and safety issues were observed.

Staff and resident records were reviewed.

Multiple topics were discussed.

Facility is to update the following by July 15, 2024:
-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: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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