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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700554
Report Date: 03/02/2021
Date Signed: 03/02/2021 04:55:49 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: 5DATE:
03/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Angie Crudo, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Angela Hood contacted Administrator, Angie Crudo, via telephone to conduct a case management inspection. Notification of deficiencies are delivered via telephone due to COVID-19 pre-cautionary measures.

During previous interviews with the Administrator, documentation was requested for resident (R1’s) oxygen use. Upon documentation review, LPA observed that there was no care plan for R1, physician’s order indicating oxygen use, or receipts indicating refills or delivery of oxygen tanks for R1. During interviews conducted with the Administrator, the Administrator stated that she would obtain documentation and submit to LPA. To date, LPA has not received documentation. Interview with the Administrator indicated that the facility does not have any procedures in place for oxygen use when a resident is not receiving hospice care. According the interview with the Administrator, this is the first time she has had a resident requiring oxygen that is not receiving hospice care. Interview with the Administrator also indicated that the facility does not have any procedures in place for obtaining and refilling oxygen, as she would call the oxygen company for R1 as needed.

Due to the information above, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page.

Exit interview was conducted with Administrator via telephone and a copy of this report and appeal rights will be provided to the facility via email. This facility shall sign and return a copy of the report to the CCLD and print a copy to be retained by the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2021
Section Cited

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure resident (R1’s) records were complete, current, and readily available to licensing agency staff, which posed a potential health, safety, and personal rights risk to the resident 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: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2021
LIC809 (FAS) - (06/04)
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