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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006078
Report Date: 01/28/2022
Date Signed: 02/22/2022 12:53:24 PM

Document Has Been Signed on 02/22/2022 12:53 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:ANGEL COMFORT CARE 1FACILITY NUMBER:
306006078
ADMINISTRATOR:TEVES, ANGELINAFACILITY TYPE:
740
ADDRESS:9511 LANDFALL DRIVETELEPHONE:
(714) 964-8800
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 5DATE:
01/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Angelina TevesTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Angelina Teves. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 09/09/2021 for a capacity of five non-ambulatory residents and one bedridden. Facility has a screening area in the entrance of the facility and LPA was screened upon entry. LPA observed covid signage at entrance to facility as well as posted inside the facility. LPA observed ample PPE supply.
LPA Lyman along with Licensee/ Administrator toured the facility at 10:12 AM and observed the following:
Structure: Facility is a two story, 3 bedroom, 2 bathroom house with an attached garage on the first floor and three bedrooms, 2 bathrooms and living area on the second floor for staff/ licensee. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be a mix of single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Facility has sanitizer and paper towels in the restrooms. Linens & Hygiene Supplies: Facility has bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in dining room. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility has multiple secured areas for toxins and sharps. Water Temperature: Tested and recorded between 107.6 and 108.9 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water as well as a posted emergency disaster plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medication to be stored and locked in a locked cabinet in the garage. Facility to use a medication administration record. CONTINUED ON LIC 809C DATED 1/28/2021
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGEL COMFORT CARE 1
FACILITY NUMBER: 306006078
VISIT DATE: 01/28/2022
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Resident & Staff File: Records to be are stored in a file cabinet in the garage. Reading Material, Games, and Equipment: LPA observed a sample activity schedule including games and exercise. Backyard: LPA observed a clean backyard with ample shaded seating for residents. Facility has a secured swimming pool in the yard. Exit gates are unlocked and self latching. Fire Clearance: Approved for five non-ambulatory residents and one bedridden resident on 11/08/2021.

Licensee to address the following and notify LPA when complete:
  • Please ensure fountain in front courtyard is inaccessible to residents and clean.
  • Please repair the broken threshold in master bedroom restroom.
  • Please ensure hand washing signs are posted in all restrooms.
  • Please obtain a first aid manual.
  • Please replace light bulbs in shared restroom as well as clean the light fixture.



Component III conducted during the visit. Facility is not ready to be licensed at this time.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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