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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700554
Report Date: 01/13/2021
Date Signed: 01/13/2021 04:23:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ANGIES CARE HOMEFACILITY NUMBER:
342700554
ADMINISTRATOR:CRUDO, ANGELINAFACILITY TYPE:
740
ADDRESS:8558 SHERATON DRTELEPHONE:
(916) 962-2460
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
01/13/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Angie Crudo, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Hood spoke with the Administrator, Angie Crudo, via telephone to conduct a case management visit. Today's visit was conducted by telephone due to COVID-19 and precautionary measures. The purpose of the visit is for a health and safety visit.

On 1/12/21, LPA received a phone call from a Sacramento County Public Health nurse. LPA was informed by the nurse that the facility had 3 COVID positive cases in December 2020. The Sacramento County Public Health nurse stated that they have tried contacting the facility on several occasions to get an update, however, were unable to get in contact with any facility staff.

During today's telephone call, LPA interviewed Angie. Angie informed LPA that 1 staff (S1) and 1 resident (R1) tested positive for COVID-19 on 12/16/21. The tests were conducted on 12/14/21 for both S1 and R1. Interview indicated that the facility did not report these positive cases to CCLD. LPA informed Angie of the importance of reporting to CCLD within the reporting requirement time frame.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of the report shall be submitted to CCLD. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ANGIES CARE HOME
FACILITY NUMBER: 342700554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2021
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement was not met as evidenced by: Based on interview, the facility did not report COVID-19 positive cases to CCLD within the reporting requirement time frame, which poses an immediate health and safety risk to persons in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2021
LIC809 (FAS) - (06/04)
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