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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002817
Report Date: 02/08/2023
Date Signed: 02/08/2023 03:01:22 PM

Document Has Been Signed on 02/08/2023 03:01 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:
02/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Delson Bautista, House ManagerTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with house manager Delson Bautista. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA arrived today to gather information regarding a client leaving the facility unassisted. On 1/31/23 client (C1) became upset and went to his room. Client has past behaviors of aggression and began throwing items in his room. After a few minutes staff entered clients room and observed client had broken his window and left the facility. Facility reported missing person to local police department. Resident was found and returned the following day. Manager states they placed alarms on the windows to help prevent incident from occurring again. On 2/6/23 resident was in his room when staff heard the window alarms going off. Staff entered clients room and observed client leaving. Staff tried to follow client but lost sight of him, and called the local police department. Resident was found and returned that evening. Manager states they are planning a meeting with regional center to discuss client behaviors. Manager states they have increased staffing, and client has a 1-on-1 caregiver. LPA reviewed client's LIC602 and observed client is not able to leave the facility unassisted.
Due to information gathered, LPA cited deficiencies on 809-D. Appeal rights given. Civil penalties assessed.

Exit interview given.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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 02/08/2023 03:01 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 02/08/2023 at 02:43 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: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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Administrator to send into CCL a plan of how facility will met the needs of C1 and report when the meeting with Alta regional center will take place. POC to be sent into CCL by 2/10/23.
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This requirement was not met, as evidenced by: Through record review, C1 left the facility unassisted two separate times which causes an immediate risk to the health and safety of C1.
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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:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023


LIC809 (FAS) - (06/04)
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