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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701360
Report Date: 01/19/2024
Date Signed: 01/19/2024 11:17:12 AM

Document Has Been Signed on 01/19/2024 11:17 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ANGELS HOME FOR SENIORS LLCFACILITY NUMBER:
342701360
ADMINISTRATOR:DEJARESCO, DEANE JEFFREYFACILITY TYPE:
740
ADDRESS:10070 KNOTTS DRIVETELEPHONE:
(916) 620-6235
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 5DATE:
01/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Deane Jeffrey DejarescoTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a Pre-Licensing Inspection. LPA met with Deane Jeffrey Dejaresco, and explained the purpose of the visit.

The facility currently has residents in care due to undergoing a Change of Ownership from Blessed Home for Seniors III (#342700307) to Angels Home for Seniors LLC (#342701360). The facility is an Residential Care for the Elderly and is licensed to provide services for six (6) individuals, of which 5 may be considered non-ambulatory and 1 may be considered bedridden. A resident considered bedridden may only be permitted to reside in room #6. Residents considered non-ambulatory may only be permitted to reside in rooms #1, #2, #3, #4, and #5. According to the Plan of Operations, the facility has a current Dementia Care Plan on file.

LPA Valerio and Administrator Deane toured the facility to ensure compliance with Title 22 regulations. LPA inspected the kitchen area, pantry closet, common areas, resident bedrooms (6), resident bathrooms, laundry area, garage area, and exterior plant.
The kitchen was observed to be clean and free from debris. Staff were observed cooking breakfast, assisting with resident meals, and preparing residents for a visitor. Sharps and knives were located in a cabinet under the sink, which was observed to be locked. The refrigerator and freezer were stocked with a food supply to meet Title 22 requirements. The pantry was stocked with dry goods and non-perishable food items. Common areas, such as the living room space, dinning room, and hallways were observed to be clean, fully furnished, and free from hazards.

Six resident bedrooms were inspected. Resident rooms were observed to be free from odors, had necessary furniture in good condition, and free from any obstructions of emergency exits. Residents were observed sleeping, eating, sitting in the living, and visiting with a visitor.
Continues on LIC 809 - C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ANGELS HOME FOR SENIORS LLC
FACILITY NUMBER: 342701360
VISIT DATE: 01/19/2024
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...Continued from LIC 809
Resident bathrooms were equipped with hand towels, toilet paper, skid mats, ADA compliant hand rails, trash cans, hand soap, and hand sanitizer. Bathroom fixtures were observed to be in good repair. The hot water was measured in the resident bathroom sink. LPA observed the hot water to be at a temperature of 106.0 degrees Fahrenheit, which is within the required range of 105.0 - 120.0 degrees F.

The laundry area was equipped with a washing machine and a dryer. Cleaning supplies were observed to be locked and inaccessible to residents in care.

The facility was observed to have a first aid kit, emergency supply of food, emergency supplies, an extra supply of linen and comforters, an extra supply of towels.

LPA observed the garage area. The garage is inaccessible to residents in care. The garage will be used for storage and has a back up refrigerator and freezer. The refrigerator located in the fridge will primarily be used for staff food; however, excess resident foods can be placed in the fridge.

The exterior plant was observed. The facility has a large backyard area with a cemented area that can be utilized for outdoor visits or outdoor activities. LPA observed a sitting area, a gardening area, and an emergency walk way. LPA observed the walk way to be free from obstructions. The gate leading to the outside was observed to be in working condition and able to open/close.

LPA reviewed two (2) staff files and two (2) resident files. LPA observed files to be complete with required documents. The facility was observed to have necessary signage posted along the walls of the facility. LPA requested the following documentation to be sent to LPA Valerio once completed: Updated LIC 610E, updated LIC 500, updated LIC 308, and updated Liability Insurance

The administrator was information that the pre-Licensing inspection is complete and no deficiencies were observed. Component III was completed with the licensee and there are no further questions. LPA Valerio will notify the Regional Office and Applications Analyst of the completion by close of business 01/19/2024.

An exit interview was held, and a copy of the report was provided to Administrator Deane.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
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