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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801786
Report Date: 03/26/2024
Date Signed: 03/26/2024 12:38:13 PM


Document Has Been Signed on 03/26/2024 12:38 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: 4DATE:
03/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Marivie Fabie, AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived announced to conduct a Case Management Inspection and to go over a recent SOC341 that was received regarding resident R1, who is still living in the home. LPA met with care staff, Melody Andaluz and toured the home. Administrator, Marivie Fabie arrived a few minutes later.

LPA Canela and Administrator discussed R1's current situation.
LPA provided the following information:
Health & Safety 1569.655 : Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section.
LPA also went over eviction procedures and requirements, Regulation 87224 Eviction Procedures.

LPA consulted regarding the side yard gate being able to self close and latch.
Check all exit sliding doors that they open easily.

LPA requested facility to submit a current LIC999 facility sketch (floor plan/yard) to identify all rooms use.


No citation issued .
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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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