<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201340
Report Date: 05/16/2024
Date Signed: 05/21/2024 03:46:08 PM

Document Has Been Signed on 05/21/2024 03:46 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ESTHER ANGELS CARE HOMEFACILITY NUMBER:
079201340
ADMINISTRATOR/
DIRECTOR:		ACHOLONU, ROSE C.FACILITY TYPE:
740
ADDRESS:1403 PREWETT RANCH DR.TELEPHONE:
(500) 435-8093
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 5DATE:
05/16/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Rose AcholonuTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census : 5
Method: Telephone call with CAB
COMP II Participants: Rose Acholonu (Administrator/Licensee) & Tammy Edwards (Analyst).

Administrator/Licensee participated in COMP II via telephone call with CAB analyst. Identification of the Administrator/Licensee was verified by confirming driver’s license number. During COMP II, Administrator/Licensee confirmed the understanding of Title 22. Component II was successfully completed. Administrator/Licensee was advised to email signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Administrator/Licensee's understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Tammy Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1