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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530278
Report Date: 01/23/2025
Date Signed: 01/23/2025 11:56:45 AM

Document Has Been Signed on 01/23/2025 11:56 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 0DATE:
01/23/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Delfina Rebollar, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Becky Mann conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Administrator/Applicant Delfina Rebollar. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 10/15/2024 for a total capacity of six (6) ambulatory. LPA observed the following:

Structure: Facility is one story with six (6) bedrooms, one (1) staff room, seven (7) bathrooms, living room, dining area and kitchen. There's an attached four (4) car garage in the left side of the house.

Heating/Cooling System: Central heating and air conditioning system installed with one (1) central panel.

Bedrooms: Each resident bedrooms can accommodate any ambulatory resident. All resident bedrooms were furnished with beds, mattresses, chairs, closets, linens, adequate lighting and an operable smoke/carbon monoxide detectors.

Bathrooms: The seven (7) resident/staff bathrooms have a working toilet, wash basin, and shower. LPA verified hot water temperature was measured between 108 and 114 degrees Fahrenheit.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent and chemicals are stored in locked cabinets. There is a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. Laundry room has a functional washer and dryer.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGEL GABRIEL
FACILITY NUMBER: 365530278
VISIT DATE: 01/23/2025
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Living/Family room: There's a living/family room with adequate seating for all residents and a working TV.

Linens and Hygiene Supplies: An adequate supply of linens was stored in the staff room.

Yards/Outside: Patio furniture for outdoor seating observed. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Facility sketch, CCL complaint poster, house rules, personal rights and Emergency and Disaster Plan were observed in a common area.

General items: Two (2) fire extinguishers were charged. The smoke and carbon monoxide detectors were tested and are operable. Resident records and staff records will be stored in a locked closet. First Aid kit with required components and locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 760-269-6614.

There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staffs available at the facility. Component III was completed on this day as well.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809, and LIC809C was discussed and provided to Applicant/Administrator Delfina Rebollar.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Becky Mann
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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