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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006881
Report Date: 05/12/2026
Date Signed: 05/12/2026 10:53:06 AM

Document Has Been Signed on 05/12/2026 10:53 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:ANGEL COMFORT CARE 3FACILITY NUMBER:
306006881
ADMINISTRATOR/
DIRECTOR:		TEVES, ANGELINAFACILITY TYPE:
740
ADDRESS:8931 SKIFF CIRCLETELEPHONE:
(562) 826-7205
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 0DATE:
05/12/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Angelina TevesTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Tea conducted an announced visit to the facility to complete a pre-licensing inspection. LPA met with the designated Administrator, Angelina Teves, and explained the purpose of the visit.

An application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department on December 9, 2025, for a proposed capacity of five non-ambulatory residents, with one resident permitted to be bedridden. Fire clearance was approved by the Orange County Fire Authority on April 4, 2026.

The facility is a single-story home consisting of five resident bedrooms, three full bathrooms, living room, kitchen, dining area, and an attached garage. Two exit gates are located on either side of the home; both were observed to be self-latching and secure. A shaded seating area is available in the backyard for resident use. A barbecue grill is located on the patio, and the Administrator indicated plans to establish a gardening area for residents. No safety hazards or obstructions were observed during the inspection. Recreational materials, including books, games, and puzzles, were available for resident use.

LPA observed that required postings, including Resident Rights, the facility menu, activity calendar, and Emergency Disaster Plan, were displayed in the dining area. The “See Something, Say Something” (PUB 475) poster and Ombudsman information were also prominently posted. The Administrator’s Certificate was observed in the staff office area near the living room.

Resident bedrooms were appropriately furnished. Resident bedroom doors were equipped with functioning alert systems. All beds were equipped with adequate linens and blankets, and an ample supply of linens and towels was available. Smoke detectors and carbon monoxide detectors were tested and found to be

(Inspection continued on LIC809C)

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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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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: ANGEL COMFORT CARE 3
FACILITY NUMBER: 306006881
VISIT DATE: 05/12/2026
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operational. Hot water temperature in the bathrooms measured approximately 106.3°F. Bathrooms were clean, functional, and equipped with working toilets, wash basins, and bathtubs/showers. Non-skid mats were in place to enhance resident safety.

Toxic substances were observed to be secured and locked beneath the bathroom sink and stored and locked in a cabinet in the garage. Medications will be stored in a locked cabinet in the staff office area. A fully stocked first aid kit, along with a first aid manual, was observed in the locked cabinet. Client and facility records will also be securely stored in this location. A working telephone was observed in the dining area. The facility also has a laptop and tablet available for residents to maintain communication with family members.

An adequate supply of perishable and non-perishable food was observed. All appliances, including the stove, refrigerator, dishwasher, microwave, washer, and dryer, were operational. Sharp objects were stored in a secured kitchen drawer. Emergency food, water, and additional supplies were adequately stocked in both a closet and the garage. Fire extinguisher by the kitchen was observed to be fully charged.

Based on today’s inspection, the facility appears ready for licensure. LPA conducted the Component III Orientation with Administrator Angelina Teves and informed her that final application approval will be issued by the Centralized Applications Bureau in Sacramento.

An exit interview was conducted, and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
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