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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003611
Report Date: 08/15/2023
Date Signed: 08/15/2023 04:18:07 PM

Document Has Been Signed on 08/15/2023 04:18 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: 3DATE:
08/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:MendozaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. There is currently one staff on shift.

LPA received notification that a family member was provided a letter titled "Licensee Initiated Closure Eviction - 60 days Forfeiture of License resulting from Surrender of the License". Based on LPA's observation, interviews, and record review, the Department did not receive formal notification that the Licensee intended to close the facility. LPA Valerio spoke to Licensee Antonette Tin and provided guidance regarding Facility Closures, Forfeiture of License, and Change of Ownership. Licensee was advised to review PIN 21-05 and Health and Safety Code 1569.692 to ensure proper closure of the facility.

Licensee informed LPA that this is the first time closing Precious Angels Care and will be sure to follow proper protocols. LPA informed Licensee to send her formal letter of intent to LPA by COB 08/18/2023.

LPA observed the facility to ensure no health or safety concerns. LPA observed the temperature inside the home to be a comfortable condition. Residents were observed eating snacks (peanut butter with bread, banana, and fruit) at the dinning table and inside the room. No health or safety concerns observed during the visit.

Deficiencies are being cited today and can be found on LIC 809-D. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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 08/15/2023 04:18 PM - It Cannot Be Edited


Created By: Christina Valerio On 08/15/2023 at 03:52 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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
HSC
1569.682(a)

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ยง1569.682 ... (a) A licensee of a licensed residential care facility for the elderly shall... take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following:... This requirement was not met as evidenced by:
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Licensee stated she will review H&S Code 1569.682 and PIN 21-05 to its entirety and submit a letter of intent to LPA by POC due date.
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Based on records review and interviews, the licensee provided an eviction letter to 3 out of 3 residents responsible parties on August 1st, 2023 without notifying Community Care Licensing. This poses a potential health and safety risk to residents in care
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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: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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