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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201340
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:25:08 PM

Document Has Been Signed on 05/21/2024 01:25 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
05/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:Rose Acholonu, Administrator/ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On 05/21/24 while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio conducted a component III presentation with administrator (ADM)/ applicant.

LPA discussed the common deficiencies that residential facilities for the elderly are cited on, Title 22 regulations on infection control, physical plant, personnel requirements on clearances and associations, training, emergency/disaster/food requirements, etc. ADM agreed to comply with Title 22 regulations.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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