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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701111
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:53:53 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/25/2023 11:53 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
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: 3DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Young Cho, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on 01/25/23. LPA met and toured with Administrator, Young Cho who currently holds a certificate (#6056802740) that expires on 07/23/2023.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms of which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide alarms are connected to the fire department. Fire extinguisher was last serviced on March 9, 2022. First aid kit was observed to be complete. LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have current first aid training. LPA reviewed 3 of 3 residents’ files and 3 of four staff files were reviewed.

Updated copies of the following documents were provided to LPA Renee Campbell:
LIC 500 Personnel Report
Liability Insurance

No deficiencies were observed. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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