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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003013
Report Date: 04/24/2024
Date Signed: 04/24/2024 02:14:49 PM


Document Has Been Signed on 04/24/2024 02:14 PM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH: Frazier Camille Hernandez, CaregiverTIME COMPLETED:
03:00 PM
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On April 24, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Required Annual Inspection. LPA met with caregiver Camille and informed her the reason for the visit.

LPA and Camille completed the infectious control plan questionnaire with no issues.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition The temperature was 70 degrees F. LPA observed a table in the dining area. Plates and utensils were observed to be in place. Knives are observed to not be locked in the kitchen. Dishwasher, stove, refrigerator, and microwave all present and working. This facility has a fire clearance. The facility also has a fully charged fire extinguisher and functioning smoke alarms/carbon monoxide detector and all exit doors have sound alarms. Food storage was adequate in the facility. Hot water temperature was measured at 105 F which meets the 105 F - 120F regulations.

Storage and lighting were adequate in the home. All 6 bedrooms were observed to have furniture as required by Title 22 Regulations. Bathrooms were observed to be in good repair. There's adequate linens such as sheets, blankets, etc. were observed. Cleaning supplies and toxins were found to be locked. Medications are located in the hallway closet locked .

To continue see 809 -C....
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
VISIT DATE: 04/24/2024
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LPA reviewed the exterior of the facility. There are no bodies of water on the premises.
The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards. The facility Medication Administration Record was complete and current.

LPA reviewed 3 resident files and 2 staff files. Resident's Records reviewed indicated emergency contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings and Emergency Contacts were all up to date and the facility is conducting staff training as required.

Per California Code of Regulations Title 22, no deficiencies were found.



The administrator shall submit updated copies of the(LIC 500) Personnel Report, (LIC 308) Designation of Administrative Responsibility,(LIC 610D) the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensingno later than
May 24, 2024.

An exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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