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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209498
Report Date: 10/08/2024
Date Signed: 10/08/2024 11:53:33 AM

Document Has Been Signed on 10/08/2024 11:53 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:3 ANGELS CARE LLC, THEFACILITY NUMBER:
157209498
ADMINISTRATOR/
DIRECTOR:		TUSAW, MYATFACILITY TYPE:
740
ADDRESS:13005 BIRKENFELD AVENUETELEPHONE:
(661) 319-6662
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 5DATE:
10/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Administrator, Myat TusawTIME VISIT/
INSPECTION COMPLETED:
12:06 PM
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On 10/08/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Pre-Licensing inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA met with Administrator, Myat Tusaw.

The facility is being licensed as a change of ownership. The facility is a 4 bedroom, 2 bathroom home. A fire clearance was approved for 6 Non-Ambulatory residents for a total capacity of 6. There are 5 residents present during today's inspection.

LPA reviewed residents records and observed admission agreements, medical assessments and appraisals. LPA reviewed personnel records for criminal record clearance. LPA reviewed the facility emergency disaster plan and the facility infection control plan.

LPA conducted a tour of the facility and observed the following. Facility appeared clean and at a comfortable temperature. Common areas were furnished with adequate lighting. Resident bedrooms were toured and observed to have the required furnishings. Bathrooms toured and observed to be operational. Hot water measured at 112.9 degrees F. Kitchen toured and observed to be safe for food preparation. LPA observed an adequate food supply.

Exterior tour conducted. All exits were open and free from obstructions. LPA observed the facility yard to be sufficient in size and appropriately equipped for outdoor use. First-Aid kit observed and contained all required items. Smoke detector and carbon monoxide detector observed to be operational during today's inspection. A fire extinguisher was observed to be last serviced on 07/16/2024.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued. Exit interview conducted. A copy of this report was provided to Administrator, Myat Tusaw, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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