342700836-9-8-2020-27-AS-KLEL-BT9PGL-20200908111832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700836
Report Date: 09/08/2020
Date Signed: 09/08/2020 11:18:39 AM

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:	LOVING ANGELS CAREHOME		FACILITY NUMBER:	342700836
ADMINISTRATOR:	MUNGCAL, MIRASOL		FACILITY TYPE:	740
ADDRESS:	328 CROW CANYON DR.		TELEPHONE:	9163504749
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	6	CENSUS: 6	DATE:	09/08/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mirasol Mungcal (Administrator)		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Konnor Leitzell conducted a scheduled pre-licensing inspection via tele-visit on 9/8/2020. Due to COVID-19 and precautionary measures, this inspection was done over Facetime. This is a change in ownership and currently has six (6) residents living in the facility. LPA and Applicant toured the interior and exterior of the facility, viewing the common areas, staff and residents bedrooms, bathrooms, shower room, kitchen, garage, and office. LPA observed the facility to be clean, in good repair and to have sufficient furniture in common areas, both interior and exterior. LPA observed sufficient lighting throughout the facility, and had wall lights in hallways. LPA viewed the backyard and patio, noted each room has own exit sliding door. For visitation, individuals are going through gate to residents rooms as opposed to walking through home. LPA viewed tables and chairs outside of doors with sanitizer on the tables. When entering facility and opening door through facility, LPA heard door chimes on each door. LPA observed the following posted at the facility: Resident Personal Rights, Rights of Resident/Family Councils, See Something Say Something, the Facility Sketch with evacuation routes, Ombudsman poster, and the non-discrimination clause. LPA viewed COVID-19 postings throughout facility as well. When viewing office, Admin reviewed Resident and Staff binders with LPA. No deficiencies noted in the record keeping. Extra medications were located in locked cabinet in office. LPA viewed kitchen and the thermometer for the running water was 109 degrees, and the refrigerator reading 40 degrees and the freezer reading 0 degrees. Facility had plenty of supply of non-perishables and perishable goods. When viewing the living room, many activities were seen available. LPA's saw the fire alarms and Co2 detectors were in working condition by the administrator testing them. LPA's viewed the fire extinguisher was last serviced on February 5, 2020. Administrator showed LPAs the locked cabinets for the sharps and detergents. LPAs checked and ensured the facility had sufficient dishes, flatware, cooking pans, and linens. There is currently a working land line in the facility that was viewed by LPAs. Room alert indicator was viewed in kitchen, and worked for the rooms. This is how facility is notified if resident is in need in their room.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

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: LOVING ANGELS CAREHOME	FACILITY NUMBER: 342700836
	VISIT DATE: 09/08/2020

NARRATIVE

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Facility has grab bars at the toilets, and uses central shower for all residents. Grab bars, non-skid mats and water temp was viewed at 111 degrees.

Comp III was conducted during today's inspection.

Pre-Licensing is completed with no deficiencies noted.

LPA Leitzell is to notify the analyst in the application unit of inspection being completed.

An exit interview was conducted with Mirasol Mungcal, Applicant during today's tele-visit, and a copy of this report will be provided to the facility via email (sent 9/08/2020 at approximately 11:00 A.M.) Two copies will be sent to the facility, 1 is to be signed and returned following day (9/09/2020) to CCL, and the other copy is to remain at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

LIC809 (FAS) - (06/04)

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