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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006497
Report Date: 10/24/2024
Date Signed: 10/24/2024 11:34:11 AM

Document Has Been Signed on 10/24/2024 11:34 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:ANGELIC HANDS CARE HOMEFACILITY NUMBER:
306006497
ADMINISTRATOR/
DIRECTOR:		FAJARDO, LEAH ANNFACILITY TYPE:
740
ADDRESS:24661 KIM CIRTELEPHONE:
(949) 290-3917
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Leah Ann FajardoTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Joseph Alejandre, conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Leah Ann Fajardo. .

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on January 11, 2024. The facility is to have a capacity of 6 non-ambulatory clients. LPAs observed the following. This is change of ownership with residents in care. The facility phone number is 949-455-1677.

Structure:
The facility is a one story home with 4 bedrooms, 2 shared and 2 private, staff room, 2 bathrooms, living room, dining room, family room, kitchen and an attached 2 car garage.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Resident Bedrooms:
There are 4 resident bedrooms, 2 are shared and 2 are private. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings and linens.

Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in the medication cabinet next to the kitchen. The first aid kit has all the required elements. Medications are stored in the medication cabinet which is kept locked.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELIC HANDS CARE HOME
FACILITY NUMBER: 306006497
VISIT DATE: 10/24/2024
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Bathrooms:
Both bathrooms have working showers and toilets. All bathrooms are clean and operational.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hall closet.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review. The emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food served for one week.

Food Service:
There is a 2 day supply of perishable food and a 7 day supply of non-perishable food on hand in the kitchen. LPA observed a 3 day supply of emergency food and water.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors tested operational. The Fire Extinguisher in the kitchen is fully charged and mounted on the side of a cabinet.

Appliances:
There is a convection stove, an oven, microwave oven, refrigerator and dishwasher in the kitchen. The washer and dryer are in the garage All appliances are clean and operational.

Toxins:
The cleaning supplies are kept locked under the kitchen sink. The knives are kept locked under the kitchen sink.

Water Temperature:
Hot water was measured in both bathrooms. Hot water measured at 111.9 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELIC HANDS CARE HOME
FACILITY NUMBER: 306006497
VISIT DATE: 10/24/2024
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Resident & Staff Files:
Resident and Staff Records will be kept locked in the medication cabinet.

Reading Material, Games, Equipment & Materials:
Games and puzzles are stored in the family room.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority Inspector Ryan Boselo on April 23, 2024.

Component III:
Component three was waived because the Applicant is a Licensee at another Licensed facility.

Facility is ready to be licensed.

Applicant was informed today that the final approval will be processed by CAB (Cental Application Bureau) in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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