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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804200
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:12:01 PM


Document Has Been Signed on 08/20/2024 02:12 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:ANGELS ASSISTED LIVING LLCFACILITY NUMBER:
496804200
ADMINISTRATOR:QUIJADA, CLAUDIAFACILITY TYPE:
740
ADDRESS:5525 CARRIAGE LANETELEPHONE:
(707) 791-3172
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:5CENSUS: 4DATE:
08/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Claudia Quijada, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen was at facility delivering findings of a complaint investigation and conducted a case management due to additional issues found during investigation. LPA met with Claudia Quijada, Administrator.

During complaint 21-AS-20240606100350 investigation, an allegation resident did not receive medications as prescribed was investigated and although the individual was not a resident of this licensed facility, when LPA entered facility on 6/7/2024 LPA observed medication closet unlocked with all residents’ medications accessible and pre-poured for each resident including previous individual for at least a full day (see pics). LPA is citing facility for (87465(h)(2) leaving centrally stored medications accessible to persons other than employees and for 87465(h)(5) each resident's medication not being stored in its originally received container.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ANGELS ASSISTED LIVING LLC
FACILITY NUMBER: 496804200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...
This requirement is not met as evidenced by:
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Admin to conduct staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit date of training to LPA by POC due date of 8/21/2024 &.
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Based on LPAs observation medication closet, housing centrally stored medications was left unlocked, with refrigerated insulin medications included. This is an immediate health & safety risk to residents in care.
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 Administrator to submit documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance. POC due date 8/27/2024 to CCL to clear the citation..
Type B
09/03/2024
Section Cited
CCR87465(h)(5)

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87465(h)(5) Incidental Medical and Dental Care-The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. This requirement was not met as evidenced by:
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Administrator to ensure medications are not pre-poured in advance and ensure all staff handling medications and assisting residents with their medication are trained as required by Health and Safety Code 1569.69.
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LPA observed that resident medications were pre-poured into daily medi-set cases for multiple full days, this is violation to regulation. This is a risk to the health and safety of residents in care.
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 Submit plan of ensuring medications are provided to residents by qualified trained staff and submit copy of LIC500 staffing schedule and list of staff that will be handling medications on each shift. POC due 9/3/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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