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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032700106
Report Date: 02/08/2022
Date Signed: 02/08/2022 11:13:56 AM

Document Has Been Signed on 02/08/2022 11:13 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ANGELO'S CARE HOMEFACILITY NUMBER:
032700106
ADMINISTRATOR:FERRER, ANGELOFACILITY TYPE:
735
ADDRESS:652 GLENBROOK DRIVETELEPHONE:
(916) 601-9236
CITY:IONESTATE: CAZIP CODE:
95640
CAPACITY: 4CENSUS: DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nilba RockeyTIME COMPLETED:
11:16 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual inspection. LPA confirmed with Administrator that staff and residents have not displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio was screened for COVID-19 symptoms with temperature taken prior to being allowed entry into the facility.

LPA Valerio discussed recent PINs, including 22-07, and reviewed facility COVID tracking procedures. The facility common areas were free from debris and clean. COVID-19 signs regarding social distancing, hand washing, infection control, and prevention strategies are placed throughout the facility. The common areas were clean and organized. During the visit, the facility was observed to be following all policies related to vaccinations, visitors, and the health and safety of the residents.

LPA Valerio and staff toured the physical plant inside and out to ensure compliance with Title 22 regulations. All emergency exits were clear from obstructions. LPA observed an emergency supply of food, water, and supplies. Medication cabinet, cleaning supplies, sharps were locked away and inaccessible to residents in care. Hot water was measured at 114.3*F. Room temperature was set to 74*F. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Resident rooms were clean and organized. Fire extinguishers were observed to be charged and within compliance with last check on 11/18/2021.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with facility staff.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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