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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700513
Report Date: 12/10/2021
Date Signed: 12/10/2021 04:13:07 PM

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:NELLIES ANGELS - ROBINFACILITY NUMBER:
342700513
ADMINISTRATOR:JOHNSON, MARNELLI PFACILITY TYPE:
740
ADDRESS:7361 ROBIN RDTELEPHONE:
(775) 224-6231
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marnelli Johnson, Administrator TIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA's) Sabrina Calzada and Cassie Yang, arrived unannounced to conduct a required annual. LPA met with Anna Burton, caregiver and explained purpose of inspection. LPA's were screened for temperature check at the door and asked to sign-in per Covid-19 precautionary measures. Caregiver contacted Marnelli "Nellie" Johnson, Administrator, who arrived shortly to the facility. LPA's completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. The facility is approved for (6) residents and (1) resident is currently on hospice. LPA's observed (3) residents in the common area and (2) residents in their private room.

LPA's and Administrator toured the interior of the facility, including (6) private resident rooms, (2) common restrooms,, kitchen, laundry, caregiver room, and common areas. LPA's observed it to be clean and in good repair. LPA's observed various Covid posters throughout. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA's and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 71* F. Fire extinguisher last serviced 12/30/2020. LPA's observed sufficient 2+day perishable and 7+day non-perishable food. LPA's observed paper towels, soap, sanitizer and covid posters in the restrooms. Administrator to ensure all restrooms have a trash can with lid. LPA's observed ample PPE supply. Sharps, Toxins and medications were secured. LPA's observed required postings in the facility. LPA's and Administrator discussed vaccination status of residents and staff as well as visitation protocols per PIN 21-40. LPA's observed signage/information posted at the front entrance that masks, documentation of vaccination status or negative Covid test within 72 hours are required upon entry.

LPA requested an updated copy of LIC308 (copy printed) and obtained a current copy of liability insurance and LIC500.

There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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