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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
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)
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Document Has Been Signed on 12/12/2023 04:46 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 12/12/2023 at 04:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
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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Document Has Been Signed on 12/12/2023 04:46 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 12/12/2023 at 04:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
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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