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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700314
Report Date: 05/12/2021
Date Signed: 05/12/2021 03:37:04 PM

Document Has Been Signed on 05/12/2021 03:37 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HEAVENLY ANGELSFACILITY NUMBER:
312700314
ADMINISTRATOR:ROMANOVA, LARISAFACILITY TYPE:
740
ADDRESS:6152 GREAT BASIN DRIVETELEPHONE:
(916) 865-4150
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 5DATE:
05/12/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Larisa RomanovaTIME COMPLETED:
03:15 PM
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On 5/12/2021 at 2:26pm, Licensing Program Analyst (LPA) Sarena Keosavang contacted the Administrator, Larisa Romanova, via telephone to conduct an unannounced Case Management visit. This visit was conducted via telephone due to COVID-19 and precautionary measures.

The purpose of the telephone call was to follow-up on an incident that was reported to Community Care Licensing (CCL) on 5/12/2021. The report indicated that facility staff are not following COVID-19 guidelines. Facility staff are not wearing mask while caring for residents. Staff are also not wearing masks while there are visitors at the facility.

LPA Keosavang interviewed Larisa regarding staff not wearing masks at the facility. The interview with Larisa indicates that all residents have been vaccinated. Larisa stated she attended a webinar 10 days ago which provided conflicting information in regards to mask requirements. LPA went over Provider Information Notifications (PINs) with Larisa. LPA notified Larisa that if staff continues to not wear masks while caring for residents then citations will be given to the facility. Larisa stated she will notify all staff to wear face masks while caring for residents.

At this time, deficiencies are not being cited.

A copy of this report has been emailed to the facility and the Administrator was advised that a signed copy of this report shall be emailed to LPA.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2021
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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