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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003013
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:27:14 PM


Document Has Been Signed on 09/17/2024 12:27 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: 4DATE:
09/17/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Simranjit Bhatia, LicenseeTIME COMPLETED:
12:30 PM
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On September 17, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Post Licensing Inspection. LPA met with Sim Bhatia, Licensee, and informed her the reason for the visit.

This Post Inspection is because the facility has 2 complaints at this time and wanted to check in on the residents and staff. The facility has been licensed for 1 year. Their total capacity 6. LPA will concentrate on the facility's medication and documentation in the files. LPA reviewed the facilities resident's files and staff files. LPA also reviewed the Medical Administration Records for the residents.

Fire extinguisher was CURRENT and ready for emergency use. Smoke Alarms and carbon monoxide detectors were in good condition. First Aid was complete with scissors tweezers and thermometer and guide. Licensee has 2 employees and 2 on calls that have fingerprint cleared and a current First Aid Certificate. The Fire Clearance is for 6 NON-AMBULATORY, OF WHICH 1 MAY BE BEDRIDDEN. APPROVED HOSPICE WAIVER FOR 5. The facility serves RCFE/DEMENTIA.

LPA reviewed all resident files which included Service Plans, Admission Agreements, Emergency Contact,, physician reports, and Service and assessments. Staff files included first aid certificates, Criminal Clearances, health screens and emergency contacts list.

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

An exit interview was conducted and a copy of this report was given to Sim.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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