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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920122
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:54:41 PM

Document Has Been Signed on 07/15/2024 03:54 PM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ANGELS SUNRISE VILLA INC.FACILITY NUMBER:
315920122
ADMINISTRATOR/
DIRECTOR:		KUMAR, ALPESHFACILITY TYPE:
740
ADDRESS:2060 DONOVAN DRIVETELEPHONE:
(916) 847-0842
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 6CENSUS: DATE:
07/15/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Alpesh KumarTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): zero
COMP II Participants: Alpesh Kumar
Interview Method: Telephone interview

On July 15, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, advertising

2. Pool usage, activities, medication storage

3. General provisions/ prelicensing inspection readiness

SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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