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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801786
Report Date: 10/16/2023
Date Signed: 10/16/2023 03:23:07 PM


Document Has Been Signed on 10/16/2023 03:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ANGEL'S CREST HOMEFACILITY NUMBER:
486801786
ADMINISTRATOR:FABIE, MARIVIEFACILITY TYPE:
740
ADDRESS:258 DARLEY DRIVETELEPHONE:
(707) 644-3687
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Marivie Fabie, AdministratorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa, arrived unannounced to conduct an Annual Required Inspection and met with Marivie Fabie, Administrator.

LPA/Administrator toured the facility and made the following observations: the facility was a comfortable temperature and free from obstructions. Extra hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in residents' bathrooms measured 118 degrees F which is within regulation. Cleaning products and other toxins are locked and located under the sink in kitchen. Resident rooms were furnished per regulation. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked.

Fire extinguishers were last inspected 7/22/23. Smoke detectors located throughout the facility and carbon monoxide detector were tested and functional. Last Disaster Drill conducted on 9/1/2023. Fire Dept. conducted annual inspection on 10/16/2023. Exit doors have auditory alert system that were functional at time of visit. Required postings were observed. LPA initiated file review of 5 Residents and 2 Staff records. Administrator Certificate for Marivie Fabie, 6021180740, expires on 11/29/2024. Staff have required First Aid and CPR certificates. Training records were reviewed. Residents have medical assessments and needs and services plans are updated.

No deficiencies found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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