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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002817
Report Date: 12/09/2022
Date Signed: 12/09/2022 04:22:37 PM

Document Has Been Signed on 12/09/2022 04:22 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
CHICO - RESIDENTIAL, 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: 2DATE:
12/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Delson BautistaTIME COMPLETED:
05:00 PM
NARRATIVE
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On 12/9/2022, LPA Tryon visited the facility to follow up on an Incident Report dated 12/3/2022. On that date, Resident R1 was able to leave the facility unattended, and was brought back home by Roseville Police. The staff was not aware that R1 was gone until the police brought him home. In reviewing resident's Physician Report, it was learned that R1 is not able to leave the facility unassisted, and has a history of wandering behavior

LPA met with House Manager Delson Bautista. We discussed the events around the Elopement. The staff stated she had checked on R1 between 8:00 p.m. and 9:00 p.m. and he was in his room. At about 10:00 p.m. the police came to the door and returned R1 home. She had not been aware that R1 had left.

The staff involved is no longer working at the facility.

Staff level has been increased to at least 2 staff present morning, afternoon, and NOCs. Sometimes, there will 3 staff present. The home is doing a refresher course for incidents, including training on AWOLS and how to work with clients. A new alarm system is scheduled to be in stalled on December 19.

At this time, it appears that staffing was not adequate to ensure that residents were safe, as R1 was able to leave without being noticed.

The following deficiency is cited as per Title 22 Regulations. Appeal Rights provided, Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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Document Has Been Signed on 12/09/2022 04:22 PM - It Cannot Be Edited


Created By: Todd Tryon On 12/09/2022 at 03:47 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ANGEL CARES HOME, LLC
FACILITY NUMBER: 315002817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2022
Section Cited
CCR
80078(a)

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The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met, as evidenced by: through review of Incident Report dated 12/3/22 and staff interview, it was learned that resident R1 was able to leave the
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The facilty will ensure that staff is of adequate number and adequately trained to meet the needs of the residents.
The facility has taken action by terminating employment of staff involved; increaseing staffing levels on all shifts so that there are at least 2 or 3 staff in the home at all times
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facility alone and unnoticed by staff, walked away from the facility, and was brought back home by Roseville Police. This caused an immediate risk to the health and safety of R1.
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residents are present; and has intiated re-training of staff regarding incidents, including training on AWOLS and how to work with clients. A new alarm system is scheduled to be in stalled on December 19. Administrator will submit documenation of plan of actions taken to CCL by 12/12/2022.

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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:Troy Ordonez
LICENSING EVALUATOR NAME:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
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