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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700314
Report Date: 09/09/2025
Date Signed: 09/09/2025 12:24:15 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2025 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250710154744
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: DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Lora RomanovaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Staff retained a resident with a prohibited health condition
Due to staff neglect, resident sustained a pressure injury
Due to staff neglect, resident sustained multiple bruises
Staff did not notify authorized representative of incident
INVESTIGATION FINDINGS:
1
2
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13
 On 9/9/25, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator to deliver investigation findings.
LPA reviewed resident records, facility records, and conducted interviews.
LPA finds that facility met Tittle 22 requirements.
Records and interviews found that licensee identified and sought medical care for a pressure injury that started internally then surfaced. Records show R1 received a Dr. office visit, ultrasound to assess, and 2 ER visits before the wound was staged. R1 was hospitalized before returning to the home on hospice. Once the wound was staged, R1 was not retained in the home.
R1 has advanced denmetia and mobility issues. Bruises were noted as incidental to R1's, at times, uncontrolled movement while in bed.
Throughout R1's care, R1's spouse is a resident. Husband and family share POA and are regularly informed of R1's status.
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 and report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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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