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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530278
Report Date: 01/09/2025
Date Signed: 02/13/2025 02:28:03 PM

Document Has Been Signed on 02/13/2025 02:28 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ANGEL GABRIELFACILITY NUMBER:
365530278
ADMINISTRATOR/
DIRECTOR:		REBOLLAR, DELFINAFACILITY TYPE:
740
ADDRESS:20371 TONAWANDA RDTELEPHONE:
(760) 269-6614
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6CENSUS: DATE:
01/09/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Rebollar, DefinaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Facility Type: RCFE
Application Type: Initial
Capacity:6
Census (NA)
COMP II Participants: Rebollar, Delfina owner/admin
Interview Method: Telephone


On 1/9/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Hao Nguyen
LICENSING EVALUATOR NAME: Victoria Morales
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: 02/10/2025
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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