Community Care Licensing

Document Has Been Signed on 10/26/2023 09:05 AM - It Cannot Be Edited

FACILITY NAME:	ANGIES CARE HOME		FACILITY NUMBER:	342700554
ADMINISTRATOR:	CRUDO, ANGELINA		FACILITY TYPE:	740
ADDRESS:	8558 SHERATON DR		TELEPHONE:	(916) 962-2460
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY: 6		CENSUS: 6	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Angelena Crudo		TIME COMPLETED:	03:45 PM

SUPERVISORS NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023

Link to Parent Document Below:

FACILITY NAME: ANGIES CARE HOME	FACILITY NUMBER: 342700554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not comply with the section cited above in exterior doors for non-ambulatory rooms are non-operational due to outdoor constrction or room obstructions which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	LPA contactedl fire authoity tonotify them of need for an inspection. Licensee will report to CCL for when the fire marshal inspection isis speduled.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023

Link to Parent Document Below:

FACILITY NAME: ANGIES CARE HOME	FACILITY NUMBER: 342700554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

Type B

Section Cited

CCR

87411(f)

(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, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in 2 out of 2 staff not having health screens on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2023
	Plan of Correction
1 2 3 4	Licensee will sumit proof of health screen and TB testing for S1 and S2 by the POC date of 11/14/23

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023

Link to Parent Document Below:

FACILITY NAME: ANGIES CARE HOME	FACILITY NUMBER: 342700554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

Type B

Section Cited

CCR

87412(b)

(b) Personnel records shall be maintained for all volunteers and shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in 2 of 2 staff files to lack required records and training docuentation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2023
	Plan of Correction
1 2 3 4	Licensee will complete staff files for all required documents. To be cleared by POC visit.

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interview, the licensee did not comply with the section cited above in S1, who was present while licensee was not, does not have med training but was responsible for med dispensing. This posed a potential risk to residents
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Proof of S1 medication training to be submitted by POC date of 10/27/23.

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023

Link to Parent Document Below:

FACILITY NAME: ANGIES CARE HOME	FACILITY NUMBER: 342700554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

Type B

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in [count] out of 3 of 6 residents did not have pre-appraisals on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2023
	Plan of Correction
1 2 3 4	Resident reappraisals will be created. POC to be cleared by visit.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023