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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804151
Report Date: 04/16/2024
Date Signed: 04/16/2024 04:42:11 PM

Document Has Been Signed on 04/16/2024 04:42 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ANGIE'S ADULT CAREFACILITY NUMBER:
486804151
ADMINISTRATOR/
DIRECTOR:
MAMSAANG, ANGELITA CFACILITY TYPE:
735
ADDRESS:401 DONEGAL DR.TELEPHONE:
(707) 631-2999
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 3DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Angelita MamsaangTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Administrator Angelita Mamsaang.

This facility has a fire clearance for six ambulatory residents. This facility has six resident rooms. The largest resident room has a full private bathroom. There are two full common bathrooms. Two bedrooms share one full bathroom. There is a laundry room. The backyard has a shed. There is a locked closet for medications. Common areas and resident rooms were toured.

LPA reviewed three resident files and one staff file.

Licensee inquired about what is required if a resident wishes to be left alone at the facility without staff. LPA stated the client has to be deemed able to be left alone by themselves by a planning team that includes responsible party and doctor. If the planning team deems the resident able to be left alone at the facility without staff then the licensee shall submit to Community Care Licensing for an exception for the resident.

Several other topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by May 1, 2024:
-LIC 308 designation of administrative responsibility
-liability insurance
-LIC 500 facility personnel or staff schedule

no deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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