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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 587003995
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:43:40 PM

Document Has Been Signed on 01/16/2025 03:43 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ANGEL WINGS INC.FACILITY NUMBER:
587003995
ADMINISTRATOR/
DIRECTOR:		JOHNSON, KENDELL SHARESSFACILITY TYPE:
735
ADDRESS:2061 STONE WOOD LOOPTELEPHONE:
(530) 749-9012
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY: 6CENSUS: DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Kendell and Michael JohnsonTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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LPA Hiratsuka conducted this unannounced annual visit.

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.

Several resident files were reviewed
several staff files were reviewed

several topics discussed.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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