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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700314
Report Date: 09/22/2021
Date Signed: 09/22/2021 02:47:52 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20210914145308
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: 6DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Larisa RomanovaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident not receiving well-balanced meals.
Resident is not being encouraged to participate as fully as their conditions permit in daily living activities.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 09/22//2021 to deliver investigation findings for complaint received on 09/14/21. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; upon entry LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

LPA reviewed resident records, facility records, and conducted interviews.
LPA finds that facility met Tittle 22 requirements.Records from R1's physician confirmed that R1 was receiving the proper diet and level of activity for their current condition. Immediate family who visit the facility often express being very satisfied with R1's care.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted, copy of report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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