306006257-7-29-2025-22-AS-SHAN-DK2PZT-20250729114603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006257
Report Date: 07/29/2025
Date Signed: 07/29/2025 11:46:34 AM

Document Has Been Signed on 07/29/2025 11:46 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ANGELS CARE GUEST HOME II		FACILITY NUMBER:	306006257
ADMINISTRATOR/ DIRECTOR:	JABONERO, JANICE RACHELLE		FACILITY TYPE:	740
ADDRESS:	432 N. COLORADO STREET		TELEPHONE:	(714) 244-5885
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 6		CENSUS: 6	DATE:	07/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:03 PM
MET WITH:	Roleando Aquino		TIME VISIT/ INSPECTION COMPLETED:	04:48 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to perform the required annual inspection. Upon arrival, the LPA was greeted by staff member Roleando Aquino, who granted access. The LPA explained the purpose of the visit, and shortly thereafter, Licensee Ruby Cruze arrived.The facility is a single-story residence consisting of six bedrooms, four of which are designated for client use, and two bathrooms. All client bedrooms were observed to be appropriately furnished, including beds equipped with necessary linens and blankets. All windows throughout the facility were screened, and the backyard featured a shaded seating area.At the time of the visit, one staff member and two clients were present. The facility has a total census of four clients, with two attending an off-site day program. Both bathrooms were observed to be clean and free of debris and mildew. All faucets and toilets were in proper working condition, and the hot water temperature measured at 105DF. Smoke detectors and carbon monoxide detectors were observed in all client bedrooms and common areas. Each device was tested and confirmed to be operational. The facility had an adequate stock of bath towels and personal hygiene supplies. Common areas were clean, free of hazards, and all passageways and doorways remained unobstructed.The facility’s first aid kit was fully stocked with all required items. All kitchen appliances were in good working order. The LPA observed an adequate food supply, consisting of at least a two-day supply of perishable items and a seven-day supply of non-perishable goods, meeting regulatory requirements. Knives, sharps, and toxic substances were secured in separate locked cabinets within the garage, making them inaccessible to clients.A review of two client files and two staff files was conducted. All files contained the required documentation. The Administrator’s certificate was current, with an expiration date of March 25, 2025.The fire extinguisher was fully charged and had been last serviced on March 14, 2025. The most recent fire drill was conducted on July 1, 2025, and records indicated that drills are performed quarterly by the Administrator.Based on the observations made during the inspection, no deficiencies were cited in accordance with the California Code of Regulations, Title 22, Division 6. An exit interview was conducted, and a copy of this report was provided to the Licensee.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Samer Haddadin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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