<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701111
Report Date: 01/27/2022
Date Signed: 01/27/2022 11:28:43 AM

Document Has Been Signed on 01/27/2022 11:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AN ANGEL GARDEN INCFACILITY NUMBER:
342701111
ADMINISTRATOR:CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:9873 TRAVELER COURTTELEPHONE:
(530) 886-9529
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 0DATE:
01/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Youngsuk ChoTIME COMPLETED:
11:45 AM
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 Analysts (LPA's) Treana White and Maja Jensen arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA's met with Administrator Youngsuk Cho who assisted LPA's in today’s inspection. Fire clearance licensed for 6 non-ambulatory residents. The facility administrator’s certificate #: 6056802740 which expires on 07/23/2023.

LPAs inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. LPAs observed all hallways and passageways to be free of clutter or hazards. LPAs observed kitchen was clean and in good repair. Facility has (7) seven day supply of non-perishables. Resident bedrooms were checked and were observed to be adequately furnished. LPAs observed adequate supply of linens. LPAs tested water temperature in client's shared bathroom measured at 117.9 degrees F. LPAs observed locked areas where items such as but not limited to, knives, medication, and toxins will be stored inaccessible to residents. LPAs toured the back yard and side of house to ensure safety.

Smoke detector and carbon monoxide in operating condition during inspection. LPAs observed fully charged fire extinguisher. First aid kit observed to be complete. LPAs observed mitigation plan completed. Emergency Disaster Plan last dated on 12/20/2021.



LPAs discussed the Component III with Administrator. Based on observation and interview it appears the facility is ready to be licensed. The report will be forwarded to the centralized application unit for continued processing. No deficiencies cited during inspection.

Exit Interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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 2