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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700554
Report Date: 03/12/2021
Date Signed: 03/12/2021 03:50:24 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:
03/12/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Angie Crudo, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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An office meeting was held today on 3/12/21 via WebEx due to COVID-19 and precautionary measures. The purpose of today's meeting was to address the Mitigation Plan LIC808 submittal, as to date the plan has not been submitted to CCLD. Also, the meeting was to address previous plan of corrections (POCs) that to date have not been submitted to CCLD.

The following Licensing staff were present:
Kevin MkNelly and Angela Hood

The following representatives /present:
Administrator, Angie Crudo

The following topics were covered during today's meeting:
  • Mitigation Plan LIC808
  • POCs
  • Civil Penalty
  • Technical Assistance-records/organization

The facility will be cited on the following LIC809-D for not submitting the Mitigation Plan LIC808 to CCLD as agreed. The facility will be re-cited for previous citation issued on 1/13/21 with a POC due date of 1/14/21, as to date POC has not been provided to CCLD. The facility failed to submit POC for citation issued on 3/2/21 with a POC due date of 3/3/21 and a civil penalty is being issued today.

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to CCL.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
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: 03/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2021
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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Type B
03/15/2021
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...

This requirement has not been met as evidenced by:
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Based on interviews with Administrator, the faciltiy did not submit the Mitigation Plan LIC808 to CCLD as agreed, which poses a potential health and safety risk to residents 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: 03/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2021
LIC809 (FAS) - (06/04)
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