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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701473
Report Date: 08/25/2025
Date Signed: 08/25/2025 12:56:53 PM

Document Has Been Signed on 08/25/2025 12:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AN ANGEL GARDEN IIFACILITY NUMBER:
342701473
ADMINISTRATOR/
DIRECTOR:
CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:10213 SUTARA WAYTELEPHONE:
(530) 280-8495
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 3DATE:
08/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Youngsuk ChoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 8/25/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met initially met with staff on duty and explained the purpose of the visit. The Licensee/Administrator Youngsuk Cho (S1) was notified and arrived shortly after.

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents. Per fire clearance, all residents may be non-ambulatory. Facility has a hospice waiver for 2 residents.

Initial Observation: Upon arrival LPA was greeted by staff on duty (S2). Present during this visit were 3 residents in care, with one staff on duty. 1 resident was in the living room area, 1 resident was observed sitting at the dining table doing activity and 1 resident was in their bedroom. LPA observed required posters and facility license at the entrance. Room temperature was at 74 degrees Fahrenheit upon arrival.

Physical Inspection:

Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the inside of the facility to be clean and in good repair at this time. LPA inspected 4 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. 1 resident bedroom is currently vacant. LPA measured the hot water temperature in the 1 of 2 bathrooms to be at 117 degrees Fahrenheit. Both resident bathrooms were observed to be in clean and good repair at this time.

Fire extinguisher was observed in the kitchen/dining area and was last inspected on 7/17/2025. Smoke and carbon monoxide detectors were observed throughout.

{LIC809-1}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 II
FACILITY NUMBER: 342701473
VISIT DATE: 08/25/2025
NARRATIVE
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In the kitchen area, LPA observed sufficient seven day non-perishable and two day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Proper storage of food items were observed. Kitchen refrigerator and freezer were maintained at regulatory temperature. LPA observed medications and lancet to be stored in a kitchen drawer that did not have a lock. Insulin medications and injections were observed in the kitchen refrigerator, not locked. Another medication, Mucinex, was observed in another drawer. Per S1, that belongs to a staff and immediately removed the medication and placed it in the staff room. Inside the kitchen dishwasher, LPA observed a knife and scissors and were not locked.

Outdoor area was inspected. LPA observed outdoor furniture for resident use. Emergency walkways were observed to be unobstructed. Fence and gate were in good condition. LPA provided advisory to place a ramp by the exit door to the patio. Per S1, she removed the existing ramp for her other facility, since current residents can ambulate. Per review of 3 of 3 resident’s LIC602A, all residents are non-ambulatory. S1 further stated that she will purchase one for this facility.

Advisory was also provided for S1 to ensure garage is not accessible to residents if they choose to store chemicals and other dangerous items in the garage.

Record Reviews:

Review of 3 of 3 resident files (R1, R2, R3) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Advisory was provided to ensure residents with restricted health conditions have their restricted health care plan. Advisory was also provided to Licensee to ensure each resident have PRN Authorization Letter signed by their physician. Medication review of 1 residents, include review of physician orders for over-the-counter medications.

Review of 3 staff files (S2, S3, S4) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time.

LPA also reviewed fire drill/disaster drill records; facility conducts quarterly drill. Emergency Procedure Plan was reviewed. Advisory was provided to ensure Administrator will review the plan at least annually or as needed.

{LIC809-2}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 II
FACILITY NUMBER: 342701473
VISIT DATE: 08/25/2025
NARRATIVE
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Interviews:

LPA interviewed 1 staff and attempted to interview one resident but LPA is unable to understand resident’s language.

LPA requested a copy of current Liability Insurance Certificate, LIC500 and LIC308 to be emailed to LPA at arvin.villanueva@dss.ca.gov.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited.

Exit interview was conducted with S1 to discuss plan of correction and appeals. A copy of the report and appeal rights were provided upon exit.

{LIC809-3}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2025 12:56 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/25/2025 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AN ANGEL GARDEN II

FACILITY NUMBER: 342701473

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Medications were observed accessible to residents in care: medications and lancet were observed in a kitchen drawer without lock; Mucinex medication was observed in another kitchen drawer without lock; and insulin medications were observed in the kitchen refrigerator without lock. These pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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The following were correctd on site: Licensee removed the Mucinex and plance it in the staff room. Licensee installed a magnetic lock in the kithen drawer. Licensee purchased a locked box for the insulin.
Type A
Section Cited
CCR
87309(a)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Knife and a pair of scissors were observed inside the kitchen dishwasher, not locked. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Corrected on site: Licensee immediately removed the knife and scissors and placed them under the sink which is locked and not accessible to residents in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2025


LIC809 (FAS) - (06/04)
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