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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700554
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:46:27 PM


Document Has Been Signed on 12/12/2023 04:46 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
12/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:CaregiverTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived on 12/12/23 for the purpose of conducting Plan of Correction (POC) inspection for deficiencies issued on 10/24/23. LPA was greeted by caregiver. Administrator was informed but was unavailable to assist with the visit.

On 10/24/23 deficiencies were cited for resident and staff files being incomplete, fire safety violation, staff health screens, staff training and lack of resident appraisals/ needs and services plans.

Today LPA reviewed 5 resident files. 2 residents continue to not have appraisals on file. This deficiency is recited.
Staff files are unavailable. Licensee by phone acknowledge staff health screens have not been completed and there is a staff present today without fingerprint clearance. These deficiencies are cited.
The fire safety violations have been corrected..

As a result of this visit, one plans of correction (POC) is cleared.

Deficiencies are cited as a result of this visit.

An exit interview was conducted with caregiver, YB. A copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 12/12/2023 04:46 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ANGIES CARE HOME
FACILITY NUMBER: 342700554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
87355(e)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility.This requirenment was not met based on observation of S2 is present without
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Caregiver left the facility before LPA completed the visit.
Licensee will submit a plan for emergency staffing that has properly cleared and trained staff available.
Plan submitted by 12/13/23.
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clearance. This posed an immediate risk to residents.
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Type B
12/19/2023
Section Cited
CCR87411(f)

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Personnel Requirements - General(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening,
Based on statements, S1 still needs a
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Licensee will submit proof of S1's Health screen by 12/19/23.
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Health screen.
This poses a potential risk to residents
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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: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/12/2023 04:46 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ANGIES CARE HOME
FACILITY NUMBER: 342700554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
87412(c)(2)

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Personnel requirements general (c)(2) Documentation of staff training shall include:
This requirement was not met based on statements and records.
This posed a potential risk to residents
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Licensee will submit proof of all required care and medication training for S1 by the POC date of 12/19/23.

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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: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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