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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700554
Report Date: 03/28/2022
Date Signed: 03/28/2022 05:13:20 PM


Document Has Been Signed on 03/28/2022 05:13 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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:
03/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Angie Crudo, Administrator TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced on 3/28/2022 to conduct a case management inspection to follow up on a recent AWOL at the facility. LPA met with Angie Crudo, Administrator, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN-95 Mask. LPA observed resident (3) residents in the front room near the kitchen, including the (1) resident (R1) who AWOL'd from the facility on 3/12/2022.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 3/17/2022 following a phone call regarding resident (R1) leaving the facility unattended on Saturday, 3/12/22, at approximately 10:30- 11:00 am. LPA spoke to Administrator on 3/18/2022 and confirmed resident was gone for (6) hours. Administrator followed up immediately after the AWOL and contacted the police to make a report. Resident was found on the corner nearby the facility and was returned to the facility uninjured. Administrator explained that resident started to leave again on 3/16/2022 and staff realized immediately when resident was still on the driveway. Facility had one staff on duty at the time of R1 leaving the facility.

R1's physician's report, dated 3/9/2020, indicates that resident is sometimes forgetful and cannot leave the facility unattended, but he does not have a diagnosis of Dementia. Resident has not tried to leave again and has been communicating better with the staff if he needs something.

Per California Code of Regulations, Title 22, Division 6,. Chapter 8, the following (1) deficiency is issued on the 809C page.

Exit interview. Copy of report and appeal rights provided to Administrator.


SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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 03/28/2022 05:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ANGIES CARE HOME
FACILITY NUMBER: 342700554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2022
Section Cited

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87411 Personnel Requirements - General -(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
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Based on interview and record review, the LIcensee did not ensure that adequate supervision was provided to observe and prevent resident (R1) from leaving the facility unattended on 3/12/2022, for approximately (6) hours, which posed an immediate health and safety risk to resident in care.
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Administrator agrees to also follow up with the R1's physician regarding being reevaluated if he can leave by himself possibly.

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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: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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