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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701360
Report Date: 08/08/2024
Date Signed: 08/08/2024 02:33:17 PM

Document Has Been Signed on 08/08/2024 02:33 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:
08/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Kyle AranetaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio met with Facility Staff Kyle , and explained the purpose of the visit.

On 08/07/2024, The Regional Office received notification that the facility has 6 - 8 individuals living inside the facility and it was alleged that staff may be living in the garage. LPA Valerio and facility staff Kyle inspected the physical plant to ensure compliance with Title 22 regulations. LPA observed 6 bedrooms and counted 6 residents in care and 2 staff present. According to staff interviews, there is no live in care staff. LPA observed the backyard to have no outdoor storage room. LPA observed the garage. LPA observed a staff break area next to the storage area/car area. According to staff, this is utilize for staff break time during the day or night. LPA Valerio contacted Administrator Deane Jeffrey Dejaresco and explained the purpose of the visit. LPA Valerio and Administrator Deane discussed the staff break room. LPA requested an updated copy of the facility sketch be sent to LPA by 08/22/2024.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held, and copy of the report was provided to facility staff.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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