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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006257
Report Date: 08/24/2023
Date Signed: 08/24/2023 11:13:11 AM

Document Has Been Signed on 08/24/2023 11:13 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELS CARE GUEST HOME IIFACILITY NUMBER:
306006257
ADMINISTRATOR:JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:432 N. COLORADO STREETTELEPHONE:
(714) 244-5885
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 6CENSUS: DATE:
08/24/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Janic Jabonero - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection (change of location). LPA arrived at the facility at 8:40am and was greeted and granted entry by designated Administrator (AD) Janice Jabonero and Licensee Rubylyn Richardson. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 10/25/2022.

Structure:
The facility is a one-story home with four resident bedrooms, two bathrooms, living room, kitchen, dining room, laundry room, an attached two car garage and backyard. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining room. There is a back yard with one exit gate. The facility has a shaded patio set that is currently in use at the existing facility. This will be brought over to the new facility when the residents move in. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms:
All resident bedrooms had beds. Resident furniture is currently in use at the existing facility. These will be brought over to the new facility when the residents move in. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Bedrooms 2 and 3 have sliding doors leading to the backyard. Bedroom 3 has a door alarm installed and functional. AD showed LPA the alarm that will be installed in Bedroom 2.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the cabinet in the laundry room
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELS CARE GUEST HOME II
FACILITY NUMBER: 306006257
VISIT DATE: 08/24/2023
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Medications, First-Aid Kit & Book: Medication and First Aid Kit will be stored in a locked cabinet in the living room. The first aid kit has all the required elements.

Resident & Staff Files: Records will be kept locked in the medication closet.
Fire Extinguisher: LPA observed two fire extinguishers to be fully charged as indicated by the arrow placed in green zone. LPA observed a receipt for the fire extinguishers indicating they were purchased on 1/11/23

Reading Material, Games, Equipment & Materials: The facility has activity materials that will be kept in the living room. Puzzles, Bingo, card games, other games and books will also be kept for resident use.

Fire clearance: Was approved by a fire inspector of Anaheim Fire Department on 07/28/2023.
Component III: Conducted at the Pre-Licensing visit

Bathrooms: Both bathrooms have working plumbing. Hot water measured at 115.7 degrees Fahrenheit in the bathroom across from Bedrooms 1 and 2, 115.5 degrees Fahrenheit in the bathroom inside the Bedroom

Linens & Hygiene Supplies: A supply of extra linen is at the existing facility. The supply will be brought to the new facility when residents move in.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

Food Service: There is a 7-day of non-perishable supply of food on hand.

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the home. The dual detectors were tested and observed to be operational.

Appliances: Gas four burner stove, oven, refrigerator, dishwasher, microwave, washer and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview conducted and a copy of this report was provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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