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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 587003995
Report Date: 01/04/2023
Date Signed: 01/04/2023 04:55:52 PM

Document Has Been Signed on 01/04/2023 04:55 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ANGEL WINGS INC.FACILITY NUMBER:
587003995
ADMINISTRATOR:JOHNSON, KENDELL SHARESSFACILITY TYPE:
735
ADDRESS:2061 STONE WOOD LOOPTELEPHONE:
(530) 749-9012
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 6CENSUS: 6DATE:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Kendell, Michael, and Colleena JohnsonTIME COMPLETED:
05:05 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing masks. LPA was screened at the front door.

The main entrance opens to a common sitting area on the right. There is an staff room on the right of the main entrance. To the left of the main entrance leads to two full common bathroom, four residents rooms: two shared and two private rooms, and a laundry room that has a door leading to the garage. In front of the the entrance is a doorway that leads to the main common area and kitchen.

Multiple topics were discussed.

Licensee shall submit an updated facility sketch to reflect the staff room that was built along with the information for the local fire district because LPA has to order a new fire clearance for the room.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2023
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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