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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701235
Report Date: 01/12/2023
Date Signed: 01/12/2023 09:41:08 AM

Document Has Been Signed on 01/12/2023 09:41 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NELLIE'S ANGELS-NORRISFACILITY NUMBER:
342701235
ADMINISTRATOR:JOHNSON, MARNELLI PFACILITY TYPE:
740
ADDRESS:3915 NORRIS AVETELEPHONE:
(916) 436-4036
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 4DATE:
01/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Marnelli JohnsonTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) arrived unannounced to conducted a Pre-Licensing (CHOW) Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez met with Marnelli Johnson and explained the purpose of today's visit.

Facility has a fire clearance for six non-ambulatory residents. Marnelli Johnson, will be the Administrator of this facility.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen.

The facility sketch needs to be updated to reflect STD 850 fire Clearance approval. The facility resident rooms and staff rooms need to be numbered as reported on the STD 850 Fire Clearance. As a result, the facility has not passed today's pre-licensing inspection. LPA Martinez will return to the facility when the corrections have been made. Applicant was informed to call LPA Martinez when the correction has been completed.

An exit interview was conducted, and a copy of this report was given to the applicant.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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