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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601276
Report Date: 03/23/2023
Date Signed: 03/26/2023 08:02:54 AM

Document Has Been Signed on 03/26/2023 08:02 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ANGEL'S GUEST HOME #1FACILITY NUMBER:
374601276
ADMINISTRATOR:JENKINS, PATRICIAFACILITY TYPE:
740
ADDRESS:9208 BELLAGIO RDTELEPHONE:
(619) 258-2013
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 6CENSUS: 6DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Licensee McEvoyTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPAs) Debbie Correia and Elizabeth Hamilton conducted an unannounced Case Management visit to cite on an unrelated deficiency noted during a previous complaint visit conducted on February 07, 2023.

During the February 07, 2023 site visit, Licensee McEvoy was unable to provide resident records to aide in a complaint investigation. Licensee McEvoy revealed the records were in the facility garage and would take time to locate. To date the resident records were not provided.

The following deficiency was cited per Title 22 regulations on the attached 809-D. An exit interview was conducted with Licensee McEvoy and a copy of the following reports, LIC-809, 809-D and appeal rights (9058), were provided. Licensee McEvoy. Signature on this report is confirmation of receipt of these reports.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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Document Has Been Signed on 03/26/2023 08:02 AM - It Cannot Be Edited


Created By: Debbie Correia On 03/23/2023 at 08:47 AM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
87506(d)

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All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying....
This requirement was not met as evidence by:
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Licensee McEvoy will conduct an audit on resident records to ensure complete and accurate information. Licensee will organize records and house them in an accessible area. POC due date is 4/24/2023.







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Based on a records request the Licensee did not provide resident records to the Department.


This posed a potential health and safety risk to 1 out of 5 residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Simon Jacob
LICENSING EVALUATOR NAME:Debbie Correia
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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