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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608858
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:04:01 PM

Document Has Been Signed on 03/01/2022 01:04 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANGEL'S CARING HOMEFACILITY NUMBER:
197608858
ADMINISTRATOR:DANIEL D. CHOFACILITY TYPE:
740
ADDRESS:23747 VIA GAVOLATELEPHONE:
(661) 287-4526
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 5CENSUS: 4DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Norma Portunes, StaffTIME COMPLETED:
01:25 PM
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At 11:35am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Norma Portunes, who granted access to the facility. Administrator was contacted over the phone and LPA explained the reason for the visit.

LPA conducted a tour of the facility with the Staff and the following was observed:

Infection control: Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Staff stated they have sufficient PPE supplies. LPA observed all trash cans throughout the facility have fitted lids to protect from cross contamination.

Kitchen: At approximately, 11:58am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 12:20pm they were tested and observed to be operational.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 12:05pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 106.1°F. LPA observed appropriate grab bar and non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom. Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANGEL'S CARING HOME
FACILITY NUMBER: 197608858
VISIT DATE: 03/01/2022
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Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. First fire extinguisher was located in the kitchen and second in the dining room area and both were last serviced on 02/16/2022.

Outside areas: At approximately, 12:25pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Laundry is located in a detached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed.

Medications: At approximately, 12:00pm LPA observed medications are centrally stored and locked in the kitchen cabinet and inaccessible to residents in care.

Administrative: Certificate of Liability Insurance, and LIC.500 will be emailed to LPA..

No citations issued during this visit. Exit interview conducted. Copy of report emailed to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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