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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701360
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:49:56 PM

Document Has Been Signed on 05/16/2024 03:49 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ANGELS HOME FOR SENIORS LLCFACILITY NUMBER:
342701360
ADMINISTRATOR/
DIRECTOR:
DEJARESCO, DEANE JEFFREYFACILITY TYPE:
740
ADDRESS:10070 KNOTTS DRIVETELEPHONE:
(916) 620-6235
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Deane Jeffrey Dejaresco TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a post-licensing inspection. LPA was met by facility staff Kyle Arneta, and explained the purpose of the visit. LPA was later met by Administrator Deane Jeffrey Dejaresco.

LPA Valerio toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed 6 residents and 2 staff present in the facility. LPA Valerio observed the common living room area, kitchen area, garage, resident bedrooms, resident bathrooms, exterior area, and laundry room area. Common areas were observed to be free from debris and free from odors. Resident bedrooms were fully furnished with no obstruction of emergency exits. Resident bathrooms were fully stocked with paper towels, toilet paper, soap, a trash can, and hygiene supplies. Garage area was observed to be utilized for storage only. Backyard area was furnished with a seating area. The facility was observed to have an adequate supply of food. Medications, sharps, and cleaning supplies were observed to be locked and inaccessible to residents in care.
LPA spoke to staff and residents during the visit. Staff were assisting residents with ADLs and assisting with a visit. Residents were observed watching television, walking around the home, and inside their bedroom.

LPA Valerio reviewed 2 staff and 2 resident files. Files were observed to be complete and up to date.

Administrator informed LPA Valerio that the licensee would like to install cameras for the common areas of the facility and exit door ways. LPA Valerio provided guidance to administrator/licensee regarding procedures and documentation needed for video surveillance. Administrator to submit required documentation to LPA Valerio via fax or email.

Per California Code of Regulations (CCR) Title 22, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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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