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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701235
Report Date: 08/02/2023
Date Signed: 08/02/2023 02:55:47 PM

Document Has Been Signed on 08/02/2023 02:55 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
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: 6DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marnelli Johnson TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 08/02/2023 at 2:00 PM to conduct a case management visit. LPA met with Marnelli Johnson and explained the purpose of the visit.

The purpose of the visit today, is in response to resident 1's (R1) pressure injury. R1 was diagnosed with a resolved/healed stage 3 pressure injury. However, R1's pressure injury reopened. R1 is currently receiving home health for wound care, and R1 is in the process of transitioning onto Hospice. LPA Martinez requested an exemption for the stage 3 pressure injury. Marnelli reported they will continue provide updates on R1's pressure injury stage and hospice status.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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