197610408-7-12-2023-31-AS-APAA-CTNRJG-20230712130354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610408
Report Date: 07/12/2023
Date Signed: 07/12/2023 01:04:29 PM

Document Has Been Signed on 07/12/2023 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:	ANGELS HAPPY HOME		FACILITY NUMBER:	197610408
ADMINISTRATOR:	TRINANES, IRMA M.		FACILITY TYPE:	740
ADDRESS:	25808 PARADA DRIVE		TELEPHONE:	(661) 755-0130
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91355
CAPACITY: 6		CENSUS: 0	DATE:	07/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Irma Trinanes, Administrator		TIME COMPLETED:	01:00 PM

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At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an announced Pre-Licensing visit to this facility and met with the Administrator. This is an initial application. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The common areas (living room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Clients, staff records and medication will be stored in a locked cabinet by the dining area. The facility maintains a comfortable temperature at 76°F.

At 10:20am, the kitchen knives are stored in a locked drawer. The kitchen cleaning supplies are stored in a locked cabinet under the sink. Laundry detergents, cleaning supplies and other toxins are stored in a locked cabinet by the garage. LPA observed the garage to be locked and inaccessible to clients in care. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional. The first aid kit is readily available.

Facility Fire clearance was conducted on 05/15/23 and approved for two (2) Ambulatory, three (3) Non-ambulatory and once (1) Bedridden client. Dual carbon monoxide and smoke alarm system were located throughout the facility, and at 10:30am they were tested and observed to be operational. There is a fire extinguisher located in the kitchen with a date of purchase of 04/29/2023. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted in each bedroom and in the hallway wall with other posting requirements. There are four (4) bedrooms designated for clients use. Clients bedrooms were observed, to be appropriately furnished. The facility will have an awake staff. There are two (2) bathrooms in

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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: ANGELS HAPPY HOME	FACILITY NUMBER: 197610408
	VISIT DATE: 07/12/2023

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the facility. Bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to have closed tight fitting lids. At 10:40am, the hot water temperature measured at 115.76°F.

At approximately, 10:50am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a fountain that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 4 feet high all around. LPA discussed the importance of maintaining the care and supervision to meet the needs of the residents.

Component III was conducted with applicant.

No deficiencies issued with this report. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted. A copy of this report was signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC809 (FAS) - (06/04)

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