496804200-5-14-2024-21-AS-DALO-D59VET-20240514162253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804200
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:23:03 PM

Document Has Been Signed on 05/14/2024 04:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	ANGELS ASSISTED LIVING LLC		FACILITY NUMBER:	496804200
ADMINISTRATOR:	QUIJADA, CLAUDIA I		FACILITY TYPE:	740
ADDRESS:	5525 CARRIAGE LANE		TELEPHONE:	(707) 791-3172
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	5	CENSUS: 3	DATE:	05/14/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Claudia Quijada-Applicant		TIME COMPLETED:	04:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection, at approximately 10:00am on 5/14/24, and met with Applicant Claudia Quijada; Claudia has a residential care for the elderly administrator certificate, #6060386740, expires 8/24/25. This application is a change of ownership, the facility is currently licensed as Green Meadows Living #2 - #496803534; Claudia Quijada is the facility's Administrator. Facility has a fire clearance approval by the Sonoma County Fire Department for a total of five (5) capacity, five (5) non-ambulatory, of which two (2) may be bedridden-effective 1/24/2024. Bedridden rooms are #1 and #2 only. All egress and perimeter locks approved, the backyards non-fire exit gate may be locked at all times. Applicant has applied for approval of a dementia plan of operation. Applicant has also applied for an approval of a hospice waiver for two (2). Applicant has submitted a required infection control plan, and a required emergency disaster plan as part of their application packet. Facility will operate with an awake night staff, and Licensee will ensure sufficient 24/7 staffing at all times. Hot water was checked at 116.4 degrees Fahrenheit, which is within regulation. All exits were unobstructed in the home. All exit doors had auditory alarms and the alarms were working properly during the inspection. Fire extinguishers, two (2), is serviced and tagged as required- expires 8/9/24. There are eight (8) smoke alarms that also can detect carbon monoxide, all were working appropriately. Facility has a sufficient supply of food, perishable and non-perishable There is a closet used for storage of resident medications, and is kept locked at all times, has a key-code entry pad.The garage has an auditory alarm to alert staff if any residents are trying to use that door. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ANGELS ASSISTED LIVING LLC	FACILITY NUMBER: 496804200
	VISIT DATE: 05/14/2024

NARRATIVE

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LPA observed sufficient supply of cleaners, paper products, hygiene products, and personal protective equipment (PPE). Applicant stated that the garage entry door from inside the house, has an auditory alarm, is monitored to ensure residents don't have access to items stored in the garage. The backyard has patio deck furnishings for resident use; There is a ramp off the backyard patio deck accessible from the dining rooms slider door, and from resident room two (2).There is a ramp in the front of the home leading to the front door of the facility.

The facility does have emergency food items and other emergency supplies, to meet the "72 hour shelter in place" requirements. There was sufficient lighting throughout the facility in resident rooms, common areas, bathrooms, and hallways. The grounds were free of any apparent hazards, and exits were clear during the inspection. No bodies of water. No firearms. All bathrooms had grab bars for resident use, and mats/non-skid flooring for resident use. There is a sign in and sign out log at the front door. All postings required were posted, and visible upon entry into the facility.

LPA reviewed three (3) resident files.
LPA reviewed three (3) staff files.

LPA conducted a component III orientation with Applicant Claudia Quijada, on 5/14/2024.

Pre-Licensing has been completed today, 5/14/24, and the facility has no apparent hazards to health and safety observed by the inspecting LPA.

LPA will forward a copy of the completed inspection to the Application Analyst. Application Analyst will notify the applicant of the status of the application.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC809 (FAS) - (06/04)

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