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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002817
Report Date: 09/16/2021
Date Signed: 09/21/2021 11:35:55 AM

Document Has Been Signed on 09/21/2021 11:35 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ANGEL CARES HOME, LLCFACILITY NUMBER:
315002817
ADMINISTRATOR:MAMARIL, THELMAFACILITY TYPE:
735
ADDRESS:1259 CANEVARI DR.TELEPHONE:
(916) 519-7474
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 4CENSUS: 0DATE:
09/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
04:00 PM
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On 9/16/2021 LPA Tryon arrived at the facility to do a pre-licensing visit. LPA met with applicants Criselda Centeno and Anthony Bui. The home has passed fire clearance and is ready to occupy.
LPA toured the facility including common areas, kitchen, bedrooms, bathrooms, hallways, office, storage, garage and yard. There is central medication storage in the office and the office door locks. The home is clean and in good repair. No hazards were noted, there is no pool in the yard. Windows, doors, walls, screens, floors are in good condition. Temperature in the facility was comfortable. There are no stairways or ramps. Smoke detectors and carbon monoxide detector installed and functioning. Client bedrooms are nicely furnished with appropriate furniture, have plenty of storage/dresser/closet space. Beds with mattresses, pads, bedding present. There are adequate bathroom facilities for 4 residents. Hot water was tested and measured 110 degrees F, within the range of 105 to 120 degrees F. There are nightlights in the hallway. The home has appropriate hygiene supplies, bedding, towels, etc. Kitchen is in good condition, adequate supply of dishes, utensils, pots and pans, etc. There is a 7 day supply of non-perishable food. There is adequate storage for personnel and client records in the office. The home has set up folders for resident and staff files. Emergency exit plan posted, LIC 610. Personal rights posted, complaint poster, appropriate COVID posters.
There is adequate space in the yard for client activities and two sitting rooms in the house. Home has activity supplies.
First aid supplies present. Washer/dryer present. The home has an operating land-line telephone, emergency lighting available. Vehicle to be used for residents is licensed, appropriately insured and in good condition.
At this time the home appears to meet regulations.
Licensee has already been operating several other licensed ARFs for about 5 years. Therefore, Component III Orientation is waived at this time.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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