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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700314
Report Date: 08/26/2022
Date Signed: 08/26/2022 01:28:52 PM

Document Has Been Signed on 08/26/2022 01:28 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: 6DATE:
08/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Larisa RomanovaTIME COMPLETED:
01:15 PM
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An office meeting was held on August 26,2022 at 12:30 PM on a Microsoft Teams Meeting video conferencing system review the stipulation adopted on April 7, 2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period.

The following were in attendance: Regional Manager Alycia Berryman, Licensing Program Manager Maribeth Senty, Licensing Program Analyst Kevin Mknelly and Licensees for Heavenly Angels, Larisa Romanova.

Alycia Berryman discussed the purpose and elements of this type of meeting.

The Stipulation was reviewed with the Licensee who expressed their understanding.

Items discussed at the meeting included, but not limited to:
Stipulation contents
· Findings
· Revocation of License- Stayed with Probation conditions
· Exclusion- stayed with probation
· Future Application for a license, registration, certification or approval
· Tolling of probationary period
· Violation of Stipulation Term
· Completion of probation
· Violation of stipulation terms
· Completion of probation and future applications

Report continued...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: HEAVENLY ANGELS
FACILITY NUMBER: 312700314
VISIT DATE: 08/26/2022
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· Department’s Authority
· Monitoring Fee
· Waiver of Hearing Rights
· Waiver of Appeal/Modification Rights
· Waiver of Claims
· Public Record
· Signatures
· Counterparts
· Effective Date April 7, 2022
· No Oral modification

The Licensee/Respondent/Representative stated they would abide by the following:
ꞏ Abide by the contents/terms of the Stipulation (submit all documents timely)
ꞏ Operate the facility in strict compliance with the regulations and statutes governing the operation of a
residential care facility for the elderly.

CCLD will do the following:
ꞏ Increase monitoring

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. A virtual exit interview was conducted, and a copy of this report was provided via email for a signature. Administrator agreed to return a signed copy to CCLD by COB 8/26/22.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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