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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701111
Report Date: 01/09/2025
Date Signed: 01/09/2025 10:54:13 AM

Document Has Been Signed on 01/09/2025 10:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AN ANGEL GARDEN INCFACILITY NUMBER:
342701111
ADMINISTRATOR/
DIRECTOR:
CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:9873 TRAVELER COURTTELEPHONE:
(530) 886-9529
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Youngsuk ChoTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with Administrator Youngsuk Cho, and explained the purpose of the visit.

LPA Valerio and Administrator Youngsuk toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed resident bedrooms to be clean and fully furnished. Resident bathrooms were observed to be sanitary. Hot water faucets delivered water within the regulatory range of 105.0 - 120.0 degrees F. Common areas, including the kitchen, dinning area, living room area, and hallways were observed to be fully furnished, free from debris, and clear of obstructions for emergency exits. LPA observed the fire extinguisher to be within compliance. Heating/Air conditioning, carbon monoxide detectors, and alarms were observed to be in working condition. The facility was observed to have an adequate food supply that was in good quality. Medications, sharps, and toxins were observed to be locked and inaccessible to residents in care. No health or safety concerns were observed.

LPA observed residents being assisted with physical therapy visit, eating breakfast, listening to music, and doing morning ADLs. Staff were observed to be conducting daily household chores, assisting residents with ADLs, preparing meals/snacks, and checking on residents.

LPA Valerio went over the new dementia care regulations for Title 22, reviewed staff files, and reviewed resident files. Files were observed to be up to date with required annual documentation.

LPA Valerio requested the following annual documents be sent via fax: LIC 500, LIC 308, LIC 610E, Proof of Control of Property, and any updates to their program services/procedures

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was held with Administrator Youngusk Cho, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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