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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003611
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:18:49 PM

Document Has Been Signed on 09/01/2022 02:18 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PRECIOUS ANGELS CAREFACILITY NUMBER:
347003611
ADMINISTRATOR:ALEJO, GLORIAFACILITY TYPE:
740
ADDRESS:8983 RICHBOROUGH WAYTELEPHONE:
(916) 549-2724
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Facility StaffTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct annual visit.  LPA met with facility staff and explained the purpose of today's visit.  The facility is licensed for 6 non ambulatory, and has a hospice waiver for 2. LPA observed 6 residents in care. Administrator/Licensee gave facility staff permission to sign on their behalf.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. Resident rooms were furnished with required furnishings. Resident bathrooms were stocked with paper towels, soap, hand sanitizer, and a trash can with a lid. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 76*F, which is within the required range of 68-85*F. The hot water temperature was measured at 109.5*F, which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA requested the following items to be submitted:
Designation of Facility Responsibility (LIC308), Updated Liability Insurance, Personnel Report (LIC500), Administrator Certificate, Emergency Disaster Plan

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited.  An exit interview was conducted with facility staff, and a copy of this report was provided. 
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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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