374603284-12-11-2025-08-AS-CLOZ-DP9RYP-20251211122639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603284
Report Date: 12/11/2025
Date Signed: 12/11/2025 12:28:46 PM

Document Has Been Signed on 12/11/2025 12:28 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ARCHANGEL'S RESIDENTIAL CARE		FACILITY NUMBER:	374603284
ADMINISTRATOR/ DIRECTOR:	DELA CRUZ, CHARISE		FACILITY TYPE:	740
ADDRESS:	7141 BULLOCK DRIVE		TELEPHONE:	(619) 267-7662
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY: 5		CENSUS: 3	DATE:	12/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:24 AM
MET WITH:	Charise Dela Cruz, Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:26 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility's history was reviewed prior to the visit. LPA identified herself and was granted entry by caregiver Arian Ysais. LPA discussed the purpose of the visit with caregiver Ysais and licensee Charise Dela Cruz who later arrived and joined the visit. According to the facility’s license, there may be a maximum of 5 residents, all of whom may be non-ambulatory in bedrooms # 1 - 4 at any given time at the facility site. The facility is approved for 2 hospice residents. During today’s inspection, the facility’s current census is 3 residents living at the facility. There were 2 residents present at the facility site during the inspection. LPA inspected the interior and exterior of the facility and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. There were at least 2 days of perishable food, and at least 7 days of non-perishable food present. Cooking, dining equipment and utensils were present, and all safely stored. Toxic chemicals and poisons were inaccessible to residents. Medications were properly labeled, as required, and stored in locked area, which LPA inspected. [CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 7

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)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ARCHANGEL'S RESIDENTIAL CARE	FACILITY NUMBER: 374603284
	VISIT DATE: 12/11/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. The facility fireplace was inaccessible to the residents. Per licensee Dela Cruz, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and the facility telephone were all working. Fire extinguishers were present (01) and serviced within the last 12 months. The first aid kit was complete and readily accessible.

LPA spoke with staff, and reviewed staff and resident records. LPAs visit did not raise any licensing concerns. The files that LPA reviewed contained the required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There was a deficiency observed and cited during today's annual inspection that may be reviewed on the LIC809-D page of this report along with Technical Advisories.

An exit interview was conducted with licensee Charise Dela Cruz, to whom a copy of this report, along with the Licensee/Appeal Rights (LIC9058 03/22), were provided at the conclusion of the visit. The signature below confirms that the documents were received.

LPA was provided an updated Emergency Disaster Plan (LIC610-E), Designation of Administrative Responsibility (LIC 308), and insurance updates during the visit. LPA requested licensee Dela Cruz to submit a current Personnel Report (LIC 500), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 12/11/2025 12:28 PM - It Cannot Be Edited

Created By: Carmen Lopez On 12/11/2025 at 12:11 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ARCHANGEL'S RESIDENTIAL CARE	FACILITY NUMBER: 374603284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(c)(1)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents did not have their updated physician's report on file which posed a potential health risk to persons in care.
	POC Due Date: 01/08/2026
	Plan of Correction
1 2 3 4	Facility agreed to have the residents medical provider update the LIC602's for both residents and submit to LPA via email by POC due date, 01/08/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025

LIC809 (FAS) - (06/04)

Page: 4 of 7