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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032700106
Report Date: 02/12/2024
Date Signed: 02/12/2024 02:28:14 PM

Document Has Been Signed on 02/12/2024 02:28 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 4DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff on dutyTIME COMPLETED:
02:45 PM
NARRATIVE
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On 2/1/2/24 at 10:30am Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct an annual visit. LPA met with facility staff, and discussed the purpose of the visit. The home manager, Aaron Cocjin, was made aware of this visit and gave permission to staff on duty to accommodate LPA and sign this report. Today's visit, there were 2 clients in care with 1 staff on duty.

LPA toured the facility with staff. LPA observed common areas to be clean and free from debris. Resident rooms were clean and organized with personal touches of each resident. Bathrooms were equipped with soap, paper towels, hand sanitizer, and a lid trash can. LPA observed an insect spray in bathroom #1 on the facility sketch. Staff on duty immediate put away the insect spray in a locked cabinet in the garage. The facility is furnished. The room temperature was observed at 70 degrees F. Hot water temperature was taken in bathroom #1 and was observed to be 119 degrees F. The kitchen was observed to be clean and sanitary. The facility maintains nonperishable foods for a minimum of 7 days and perishable food for 2 days. An emergency supply of food and water was observed. The garage houses additional freezer, washer and dryer, and locked cabinets for chemicals. A pull alarm system and fire extinguishers were observed to be charged and within compliance with last check on 12/8/23. Medications, cleaning supplies, and sharps were locked and inaccessible to residents in care. LPA conducted facility record review, staff records review, client records review. Additionally, LPA conducted medication review of 3 of 4 clients in care.

LPA requested the following documentation: LIC 500, LIC 308, Surety Bond, and liability insurance.

Per California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed during this visit. An exit interview was held with the staff on duty, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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 5
Document Has Been Signed on 02/12/2024 02:28 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/12/2024 at 01:28 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELO'S CARE HOME
FACILITY NUMBER: 032700106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above where during facility observation LPA observed an insect spray in bathroom #1 (from facility sketch) and is accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Corrected on site: Staff on duty put away the insect spray in a locked cabinet in the garage, inaccessible to clients in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/12/2024 02:28 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/12/2024 at 01:28 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELO'S CARE HOME
FACILITY NUMBER: 032700106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above. During medication review, there were medications from 2 clients medication boxes were observed to not have physician's orders which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee to either destruct the medications if they are no longer being used or needed, or obtain prescription order from the cleints' physician.
Licensee to submit to the Department proof of medication destruction records or new prescription order from the clients' physicians by POC due date.
Type B
Section Cited
CCR
80092.8(a)(2)(A)(2)
Diabetes. (a) A licensee of an adult CCF may accept or retain a client who has diabetes if all of the following conditions are met: (2)...a licensed professional administers the tests and injections. (A) The licensed professional may delegate to trained facility staff glucose testing provided all of the following conditions are met: 2. The licensee ensures that facility staff responsible for glucose testing receive training from a licensed professional as specified in Sections 80092.1(k) through (k)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, Licensee does not possess evidence of blood glucose test training for staff from a licensed professional. This poses a potential health and safety risk for clients in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee will ensure blood glucose test training is complete per regulatory requirements for all applicable staff and submit proof of completed training to LPA by POC due date.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5