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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700237
Report Date: 12/14/2021
Date Signed: 12/14/2021 11:23:28 AM

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:NELLIE'S ANGELS HOME CAREFACILITY NUMBER:
342700237
ADMINISTRATOR:NELLIE JOHNSONFACILITY TYPE:
740
ADDRESS:6730 SKYLANE DRIVETELEPHONE:
(916) 729-7648
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:9CENSUS: 9DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Staff- Annabelle BurtonTIME COMPLETED:
11:27 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 12/14/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with facility staff, Annabelle Burton, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA requested for facility staff to contact Administrator, Nellie Johnson, to inform her that LPA is present at the facility to conduct an annual inspection. LPA spoke to Administrator on the telephone. Administrator stated she is not able to meet LPA at the facility and gave permission for staff to assist LPA and sign report.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, four (4) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and staff completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and LPA sent a copy of the repot via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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