<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700314
Report Date: 08/28/2024
Date Signed: 08/28/2024 12:25:50 PM

Document Has Been Signed on 08/28/2024 12:25 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HEAVENLY ANGELSFACILITY NUMBER:
312700314
ADMINISTRATOR/
DIRECTOR:		ROMANOVA, LARISAFACILITY TYPE:
740
ADDRESS:6152 GREAT BASIN DRIVETELEPHONE:
(916) 865-4150
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Larisa RomanovaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/28/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with Administrator who assisted with the visit.

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. The home is very clean and residents stated they are happy with care. Medication administration procedures discussed for when one person pours medications and another person may dispense medication.

LPA reviewed 5 resident files. Files are complete and well organized. LPA and Admin discussed content and updates to needs and services plans and guidance for PRN authorization.
LPA interviewed R1 and R3. Residents stated satisfaction with care provided and living accommodations.

LPA reviewed 1 staff files. Files are complete.

LPA advised that Admin use the CARE tool be used as a guide to prepare for annual inspections and regulatory compliance.

No deficiencies are being cited as a result of todays inspection.


Exit interview conducted with licensee and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1