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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700314
Report Date: 07/26/2023
Date Signed: 07/31/2023 11:55:54 AM

Document Has Been Signed on 07/31/2023 11:55 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Larisa RomanovaTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 7/25/23 to conduct a Required-1 Year Inspection utilizing the CARE inspection tool. LPA met with Caregiver and explained the purpose of the visit . Administrator arrived to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Residents appear to have all identified care needs met.

LPA reviewed 5 resident files and 2 staff files. LPA found staff to be complete with the exception of required medication training for S1. Resident files were found to be complete with the advisories noted below.
LPA and Admin discussed the following topics: Resident needs and services plans reviewed and signed by residents, PRN administration records complete and thorough, an activity plan to engage residents to their needs and interests, having a designee present when Admin is absent and maintaining staff training for restricted health conditions.
Infection control plan is on file.

Licensee was provided a copy of liability insurance.

As a result of this inspection, a deficiency is noted.
Report reviewed with licensee . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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 07/31/2023 11:55 AM - It Cannot Be Edited


Created By: Kevin Mknelly On 07/26/2023 at 02:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HEAVENLY ANGELS
FACILITY NUMBER: 312700314

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview, the licensee did not comply with the section cited above in 1 of 1 caregiver did niot have record of completed medication training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee will submit proof of completed medication training for R1 by the POC date of 8/16/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
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