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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003611
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:15:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/17/2024 02:15 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:PRECIOUS ANGELS CAREFACILITY NUMBER:
347003611
ADMINISTRATOR:ANTONETTE TINFACILITY TYPE:
740
ADDRESS:8983 RICHBOROUGH WAYTELEPHONE:
(916) 549-2724
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 0DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Antonette TinTIME COMPLETED:
02:30 PM
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On this date, 7/17/24, at 12:48pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct their annual required inspection. LPA met with Antonette Tin, Administrator (ADM), and stated the purpose of the visit.

Present during today's visit are 0 residents and 0 staff.

LPA and ADM toured the facility and inspected each resident bedrooms. Each resident bedrooms were observed to be unoccupied. LPA observed no evidenced of anyone residing and/or working at this facility. Per interview with ADM, last residents have moved out/relocated last year. Resident and personnel files are not available for review during this visit. Per ADM, she keeps resident and personnel files at another location for security reasons, since no one is present at this facility at all times. Technical assistance was provided for licensee to keep residents and personnel files for a minimum of 3 years, as per regulation, and files needs to be available for review upon request.


Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8 - no deficiencies are being cited An exit interview held with Antonette, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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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