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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804108
Report Date: 11/22/2022
Date Signed: 11/22/2022 10:06:10 AM

Document Has Been Signed on 11/22/2022 10:06 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ANGEL'S PLACE IN MOSSWOODFACILITY NUMBER:
496804108
ADMINISTRATOR:DICHOSO, ALMAFACILITY TYPE:
740
ADDRESS:311 MOSSWOOD LANETELEPHONE:
(707) 708-2694
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
11/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Alma Dichoso (Applicant)TIME COMPLETED:
10:21 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct Pre-Licensing Inspection and Component lll. LPA met with applicant Alma Dichoso during inspection. This pre-licensing is for a change of ownership. There are five clients in care. Facility has a Dementia Care Plan approved to care for residents with dementia care needs. Hospice waiver is approved for 4 residents.

The following items were reviewed during this pre-licensing inspection:
  • Locked cabinet with sharps
  • Locked toxins
  • Smoke detectors and carbon monoxide were inspected in residents rooms and in hallway which were all working properly
  • Fire extinguisher was last charged and serviced on January 2022
  • Water temperature measured 111.2 degrees F which was in regulation
  • Resident rooms
  • Backyard
  • Client files including Physician's Reports and Care Plans.
  • Required posting at entrance of facility
  • Facility kitchen including perishable and non-perishable foods.
  • First aid kit.

Pre-licensing passed and COMP III completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation.

LPA will notify CAB of today’s Pre-licensing inspection. No deficiencies cited at today’s inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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