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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700314
Report Date: 12/29/2022
Date Signed: 12/29/2022 10:22:18 AM

Document Has Been Signed on 12/29/2022 10:22 AM - 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:
12/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Larisa RomanovaTIME COMPLETED:
10:30 AM
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On 12/29/22, Licensing Program Analyst (LPA) Kevin Mknelly, met with licensee, Larisa Romanova.

Prior to the inspection, LPA followed department Covid precautions. LPA was screened upon entering the home.

The purpose of this inspection was to conduct a health and safety check related to licensee's increased monitoring during probation.

LPA confirmed that licensee met all current training requirements. LPA toured the home. The home is well maintained and residents appeared to have needs met. LPA conducted a file review for one resident. Files are in order. Licensee and LPA discussed newly admitted R1 and options for physician contact for issues to be resolved.

LPA discussed PIN 22-24 and 22-13 and provided copy.

As a result of this inspection, no deficiencies were found.

Report reviewed and copy provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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