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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320394
Report Date: 08/30/2024
Date Signed: 09/03/2024 08:14:17 AM

Document Has Been Signed on 09/03/2024 08:14 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ANGEL'S ON WING'S LLCFACILITY NUMBER:
198320394
ADMINISTRATOR/
DIRECTOR:		CLANTON, MARILYNFACILITY TYPE:
740
ADDRESS:1440 W 92ND STREETTELEPHONE:
(310) 684-8859
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 6CENSUS: 0DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:MARILYN CLANTONTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Troy Watson conducted an unannounced visit to Angels On Wing’s LLC on 08/30/2024 at 03:07 PM. The LPA met with the Administrator Marilyn Clanton. The purpose of the visit was explained. Facility is licensed to serve 2 non-ambulatory and 4 ambulatory residents and currently has a census of (0). The Hospice waiver is for 3 residents. The facility does not handle any of the resident’s money. This home is a one-story home consisting of: (6) resident bedrooms, (2) bathrooms, (1) living room, (1) kitchen with a dining area, laundry room (located in the hallway, one office and a shaded patio area located in the back of the facility.

The resident’s bedrooms had the required furniture, lamps, adequate bed linen and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked and found to be sanitary. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold and mildew. The water temperature measured between 115.2 F and 116.3 F in each bathroom and in the kitchen. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas such as the dining room and living room were clean and clear of hazards; doorways were free of obstructions.

Evaluation continued on LIC809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394
VISIT DATE: 08/30/2024
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Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supplies were checked and adequately stocked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. All (10) Smoke/carbon detectors worked properly; the residence has (4) four fire extinguishers that are fully charged. First Aid kit was checked and properly stocked with scissors, tape, gauze, and certified manual. No bodies of water were observed around the facility. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

An exit interview was conducted, and a copy of this report was provided to the Administrator Marilyn Clanton.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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