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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004079
Report Date: 11/20/2024
Date Signed: 11/20/2024 03:48:56 PM

Document Has Been Signed on 11/20/2024 03:48 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELA'S RESIDENTIAL CAREFACILITY NUMBER:
306004079
ADMINISTRATOR/
DIRECTOR:
ANGELA TALPOS O'CONNORFACILITY TYPE:
740
ADDRESS:3141 BRAY LANETELEPHONE:
(949) 326-8797
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Materesa "Tess" GalletesTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Nancy Guillen made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by staff Materesa “Tess” Galletes. Administrator (AD) Angela O’Connor arrived at approximately 2:15 p.m. and met with LPAs.

During the inspection, LPAs and staff Galletes conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with six resident bedrooms, two staff bedrooms, three bathrooms, a half bath and attached two-car garage. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened. The backyard has a shaded sitting area. LPAs observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 119.8 and 120.5 degrees Fahrenheit.

LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents and locked in the garage. Medication cabinet was observed in a locked closet in the hallway. LPAs reviewed four resident files and three staff files. All files were observed to have met all the requirements. LPAs interviewed one staff and three residents.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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