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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003611
Report Date: 08/07/2023
Date Signed: 08/07/2023 04:30:31 PM

Document Has Been Signed on 08/07/2023 04:30 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: 3DATE:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Lulu MiyashiroTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with facility staff, and explained the purpose of the visit. LPA called Administrator Gloria Alejo and arrived shortly after. LPA spoke to Licensee via cell phone.

LPA Valerio and facility staff Lulu toured the facility. Today was the staff's first day at Precious Angels Care. LPA noticed the staff was sweating due to the temperature inside the home was 85*F. The regulatory range for the temperature in the home is between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside. The temperature outside of the home was 105*F. LPA advised staff how to turn the A/C down. The A/C was turned down to 70*F and ceiling fans were turned on throughout the home. LPA observed a broken chair in the staff area. A technical advisory was provided. LPA observed 4 bedrooms. All bedrooms were equipped with beds, a chair, lamp, night stand, and closet. Resident bathrooms were fully stocked with toilet paper, paper towels, soap, hygiene supplies, non-skid mats, handrails, and a trash can. The medication cabinet was observed to be lock and inaccessible to residents in care. A first aid kit was observed. LPA reviewed the Guardian Roster. LPA did not observe facility staff (S1) associated to the facility. This poses an immediate health and safety risk to residents in care. Licensee was made aware that a civil penalty in the amount of $100.00 will be assessed on 08/07/2023. LPA attempted to review staff and resident files. There was no key available to review the files that were in the locked cabinet.

LPA requested the follow documents sent to LPA by 08/14/2023: LIC 500, LIC 610D, LIC 308, Liability Insurance.

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8 - deficiencies are being cited on LIC 809 - D. Appeal Rights provided. An exit interview held with Designated Administrator Gloria, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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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Document Has Been Signed on 08/07/2023 04:30 PM - It Cannot Be Edited


Created By: Christina Valerio On 08/07/2023 at 04:08 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRECIOUS ANGELS CARE
FACILITY NUMBER: 347003611

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Licensee stated a fingerprint transfer request will be submitted to sacasctransferrequest@dss.ca.gov by POC due date. LPA to be CC'd in the email to confirm the transfer has been completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2023 04:30 PM - It Cannot Be Edited


Created By: Christina Valerio On 08/07/2023 at 04:16 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRECIOUS ANGELS CARE
FACILITY NUMBER: 347003611

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having keys available to access the files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Licensee stated they will review section 87506(a) and submit a letter of acknowledgment and provide proof of understanding and importance of the regulation. LPA will be provided copies of staff and resident files.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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