<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345003013
Report Date: 10/02/2024
Date Signed: 12/03/2024 11:23:00 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240821160241
FACILITY NAME:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR:BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT DRTELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Michelle Fraunhoffer, CaregiverTIME COMPLETED:
11:08 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure facility has adequate food supply
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Amended: On October 2, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint #59-AS-20240821160241. LPA met with Michelle , and informed her the reason for the visit.

The Department received a complaint alleging staff does not ensure facility has adequate food supply, Staff are not properly trained, and staff does not properly document resident's medications. LPA investigated the allegations by reviewing food receipt, trainings forms and MARs (Medication Administration Records) log.

Regarding the allegation that staff does not ensure facility has adequate food supply, LPA interviewed 2 staff and 5 resident. All residents stated there’s always food in the house. According to 5 residents, the licensee will get all residents grocery list on a weekly basis and purchase everything on the lists. Kitchen area was toured along with food storage units. LPA observed at this time and during prior visits made out to this facility, that food for 2-day perishable and 7-day nonperishable quantities were sufficient to meet
To continue see 9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240821160241

FACILITY NAME:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR:BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT DRTELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Michelle , CaregiverTIME COMPLETED:
11:08 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not properly document resident's medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 2, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint #59-AS-20240821160241. LPA met with Michelle, Caregiver, and informed her the reason for the visit.

LPA investigated the allegation by reviewing the MARs (Medication Administration Report(s)) log. Regarding the allegation that staff does not properly document resident’s medication; LPA interviewed all residents (6). Interviews revealed the licensee does not write anything down after administering resident’s medications. Licensee states the MARs (medication administration record) is kept at her personal home. Licensee stated the residents can self-administer their medications or is on PRN medications. Licensee brought the MARs to the facility as LPA instructed. Prior to this date, medication distributions could not be reviewed.

To continue see 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20240821160241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
VISIT DATE: 10/02/2024
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
26
27
28
29
30
31
32
9099-C...

Based on LPA's observations and interviews which were conducted and record interviews, the preponderance of evidence standards has been met, therefore, the allegation is found to be SUBSTANTIATED, meaning, the preponderance of evidence standards has been met. The deficiency will be cited.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. Exit interview held, Appeal Rights discussed, copy of report given.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20240821160241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2024
Section Cited
CCR
87465(c)(3)
1
2
3
4
5
6
7
87465(c)(3)
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
1
2
3
4
5
6
7
The Licensee shall have residents medical file at facility at all times and document all medications given to each resident. Licensee shall document why it is important to document all medications given. This shall be completed by 10/15/2024 and submitted to LPA.
8
9
10
11
12
13
14
This is evident by the facility not having a medical administration record for any of the residents.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20240821160241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
VISIT DATE: 10/02/2024
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
26
27
28
29
30
31
32
9099-C...
the needs of the residents. The complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.


Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy was given to Michelle.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2024 and conducted by Evaluator DeAnna Williams-Lyons
COMPLAINT CONTROL NUMBER: 59-AS-20240821160241

FACILITY NAME:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR:BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT DRTELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Sim Bhajit, LicenseeTIME COMPLETED:
11:08 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly trained.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 2, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint #59-AS-20240821160241. LPA met with Sim BHATIA, Licensee, and informed her the reason for the visit.

Regarding the allegation that staff are not properly trained. LPA reviewed employee files that worked at the facility. Out of 15 potential employees on the personnel list, 3 staff were hired and worked for the licensee since the facility was licensed. One staff was employed and worked long enough to be trained; however, the staff was terminated prior to completing the trainings. ALLEGATION UNSUBSTANTIATED, meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy was given to Michelle.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6