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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003013
Report Date: 09/10/2026
Date Signed: 09/14/2026 12:05:40 PM

Document Has Been Signed on 09/14/2026 12:05 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/
DIRECTOR:		BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT OAK DRIVETELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 6DATE:
09/10/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:42 AM
MET WITH:Simranjit BhatiaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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 Note: This is an amended report of the original, created on September 10, 2026.

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a complaint investigation when deficiencies were observed. LPA met with Administrator and explained the purpose of the visit. Facility has six residents in care, hospice services for one. Facility has hospice waive for five.

Today's visit, LPA and Administrator conducted a tour of the interior and exterior of the facility. The following deficiencies were observed:
  • LPA observed a hole in the wall in R1's room.
  • LPA observed broken glass window located in the exterior sun room.
  • LPA observed door handle restraints located at R1, R2 and R3's door.
  • LPA was informed rods are lodged against sliding door to prevent elopements at night.
  • LPA observed resident (R4) to have a full bed rail.
  • LPA observed medications of Tylenol, muscle relief and Gabapentin on resident bed stand table in Bedroom R2's. Additionally, interview revealed that staff provides R2 with a full day worth of medications in the morning for R2 to self administer throughout the day. Thursday medication container was observed in R2's room. File review revealed R2 needs medication management and medication supervision.

Additionally, photos were taken of the deficiencies. As a result of today's visit, deficiencies cited. Please see LIC 809-D. Note: LPA did not cite facility for being in disrepair, as California Code of Regulation 87303(a) was cited during today's visit under the complaint investigation. The hole in the wall in R1's room and broken glass window in sun room are to be corrected concurrently with plan of correction of complaint #59-AS-20260903162352, which is due September 18, 2026.

Exit interview conducted and a copy of report and appeal rights provided.
Anthony Perez
Cassie Yang
DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/14/2026 12:06 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/13/2026 05:49 PM


Created By: Cassie Yang On 09/10/2026 at 01:15 PM
Link to Parent Document Below:
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87465(h)(1)(C)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself...
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- Medications were removed from R2's bedroom during LPA's visit.
- Licensee is submit a statement of understanding that medications are to be centrally stored and only administered to residents as prescribed.
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This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply as LPA observed Tylenol, muscle relief and Gabapentin in R2's room along with Thursday night medications, R2's LIC 602 states R2 is unable to store own medications which poses an immediate risk for residents in care.
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Plan of correction is to be submitted to Licensing by September 11, 2026.

Failure to correct by due date may result to $100 per day until corrected.
Type A
09/11/2026
Section Cited
CCR87468.1(a)(6)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...
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- Door handle restraints are removed during LPA's visit.
- Rod will no longer be used to restrict sliding door from being opened.
-Licensee is to conduct a training to all current employees on resident rights CCR 87468.1.
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This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply as there are door handle restraints on three resident bedroom doors, and a rod in the living used to lodge the sliding door from being opened at night, which poses an immediate risk for residents in care.
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Notification of completion is to be submitted to Licensing by September 11, 2026.

Failure to correct by due date may result to $100 per day until corrected.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/10/2026 03:07 PM - It Cannot Be Edited


Created By: Cassie Yang On 09/10/2026 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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- Full bedrail is to be removed, half bedrail may be installed.
- If R4 is a fall risk, then Licensee is to reassess R4 and create an fall risk plan to ensure the health and safety of R4 without a full bed rail.
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This requirement is not met as evidenced by: Based on LPA's observation, Licensee did not comply as LPA observed a resident who is not on hospice services having full bed rails which poses as a potential risk for residents in care.
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Plan of correction is to be submitted to Licensing by September 18, 2026.

Failure to correct by due date may result to $100 per day until corrected.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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