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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201863
Report Date: 09/16/2025
Date Signed: 09/16/2025 03:05:27 PM

Document Has Been Signed on 09/16/2025 03:05 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ANJELICA'S VILLAFACILITY NUMBER:
275201863
ADMINISTRATOR/
DIRECTOR:		NERISSA RAMOSFACILITY TYPE:
740
ADDRESS:555 FRANCIS AVETELEPHONE:
(831) 899-2644
CITY:SEASIDESTATE: CAZIP CODE:
93955
CAPACITY: 40CENSUS: 16DATE:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Ram Bangalore, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 09/16/2025 Licensing Program Analyst (LPA) Daiquiri Boyd arrived unannounced at the facility to conduct an Annual Inspection. LPA introduced herself and explained the reason for the visit. LPA met with Administrator (AD) Ram Bangalore. Administrator certificate is current.

LPA toured the facility inside and out including entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPA observed the facility to be at a comfortable temperature, clean and odor free. LPA did not observe obstructions of fire exits or fire hazards. Common areas were properly furnished and well-lit throughout. Department phone number and infection prevention information signs were posted thought the facility.

Facility capacity is 40, with a current census of 16. Residents do not share bedrooms. Fire extinguishers have been serviced as of 08/16/2024 and are in good standing with charge. Water temperature was checked in the bathroom used for bathing the residents and read at 105 degrees Fahrenheit. LPA discussed the delay time for the water to get hot. AD showed LPA Boyd the instant hot water tank on the premises that he just had installed. AD stated that the plumbers that installed the system explained there is a problem with the water mixing hot and cold and they are to come back to address this issue further. LPA Boyd took pictures of the current progress of the instant water tank.

LPA observed the required 7-day supply of non-perishable food and 2-day supply of perishables food items to be properly stored. The facility cook explained that the food is delivered daily so there is always fresh food available. Knives & cleaning supplies were observed to be locked and inaccessible to residents.

LPA reviewed 6 staff files which are current and training is up to date. LPA reviewed 6 resident files.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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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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)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ANJELICA'S VILLA
FACILITY NUMBER: 275201863
VISIT DATE: 09/16/2025
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Facility serves dementia clients and LPA found that all auditory alarms were working properly during this visit.

Centrally stored medications were observed during this visit. LPA reviewed a random sample of client medications, including the Centrally Stored Log and the Medication Administration Record (MAR).
Medications were logged correctly and dispensed correctly. All dates for medications matched across record logs for date started and date received. The MAR showed that residents were receiving medications 3 x day, but the pills were popped on one sheet instead of sheets indicated for AM, PM, etc. LPA conducted a pill count and found all medications were properly dispensed in the correct quantity and on time.
LPA, with AD discussed with staff Sonia Sab, best practices for medication tracking.

No deficiencies were issued on this day.

Facility to provide the following documents to Licensing by 09/30/2025: LIC500, Proof of Insurance/Surety Bond

A copy of this report was left with AD whose signature confirms receipt.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
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