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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881572
Report Date: 06/14/2024
Date Signed: 06/14/2024 01:08:22 PM

Document Has Been Signed on 06/14/2024 01:08 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGEL'S HAVEN CARE ASSISTED LIVING TEMECULA LLCFACILITY NUMBER:
331881572
ADMINISTRATOR/
DIRECTOR:		RICARDO GARCIAFACILITY TYPE:
740
ADDRESS:32056 DAYSPRING WAYTELEPHONE:
(951) 452-1216
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 6CENSUS: 5DATE:
06/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Applicant, Ricardo Garcia TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 6/14/2024, Licensing Program Analyst (LPA), Janette Romero made an announced visit to conduct a pre-licensing evaluation and met with Applicant, Ricardo Garcia. A change of ownership application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Central Applications Bureau (CAB) in February 2024. Fire clearance was granted on 4/23/2024 for total capacity of six (6) non-ambulatory residents.

LPA toured the facility with Applicant Garcia. During the tour, LPA observed the facility is made up of a one (1) story home with five (5) resident bedrooms, one (1) staff room, four (4) bathrooms, a kitchen, dining room, living room, and attached garage. The facility has a central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Applicant Garcia tested one (1) of the smoke alarm/carbon monoxide detectors and LPA observed it to be operational. Resident bedrooms are each furnished with a bed, chair, and night stand. Bathrooms have a working toilet, wash basin and have paper towels, toilet paper, and soap readily available. LPA toured the kitchen and observed the knives to be secured in a locked kitchen drawer and cleaning solutions and disinfectants secured in a locked kitchen cabinet under the sink. LPA observed the stove to be operational. Refrigerator/freezer are in working condition and the facility had a 2-day supply of perishable foods and 7-day supply of non-perishable foods. The facility also has adequate seating for meals for all residents. Medications are secured in a medication cart stored near the dining room. LPA observed additional clean linens and towels stored in hallway closet. Emergency water supply is stored in the garage. A wood wall secured the entire backyard. There is a swinging self-latching gate on the right side of the property. Indoor and outdoor pathways were free of obstructions. There was no bodies of water observed on the premises. Let-Us-No poster, emergency phone numbers, and exit route/maps are visibly posted near the entrance.

During today's visit, LPA did not observe any issues or concerns. The facility's pre-licensing inspection is now complete and there are no corrections required. Applicant will be contacted to attend the COMP III at the Riverside Regional Office. Final approval of licensure will be determined by CAB.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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