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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006078
Report Date: 02/15/2022
Date Signed: 02/15/2022 10:20:56 AM

Document Has Been Signed on 02/15/2022 10:20 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
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: 4DATE:
02/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelina TevesTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a follow up 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.

At 10:05 AM, LPA toured the facility and observed the following:
  • Fountain in front courtyard is noted to be clean and sanitary. Facility has drained water from fountain eliminating risk to residents in care.
  • The broken threshold in master bedroom restroom has been repaired.
  • Hand washing signs are posted in all restrooms.
  • Facility obtained a first aid manual.
  • Facility replaced the light fixture in shared restroom. Fixture is clean and operational.


All noted items have been corrected and facility is ready to be licensed.





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: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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