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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701360
Report Date: 12/23/2024
Date Signed: 12/23/2024 01:53:56 PM

Document Has Been Signed on 12/23/2024 01:53 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:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Deane Jeffrey DejarescoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with Administrator Deane Jeffrey Dejaresco, and explained the purpose of the visit.

LPA Valerio observed two staff on shift and six residents present in the facility. LPA Valerio and Administrator toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed six resident bedrooms. Resident bedrooms were observed to be clean, free from debris, fully furnished, and free from odors of incontinence. Resident bathrooms were observed to be sanitary and fully stocked with hygiene supplies. Residents were observed to be watching television in their rooms, taking a nap, or having a visit with family. Staff were observed to be assisting residents with walking, activities of daily living, providing meals/drinks, completing laundry, and watching a movie with the residents. The facility was observed the facility heating/air conditioning, fire extinguisher(s), carbon monoxide detectors, and door alarms to be in working condition. The kitchen and common areas were observed to be fully furnished, organized, and clean. The backyard was observed to be fully furnished and had areas for outdoor visitation. No health or safety concerns were observed during today's visit.

LPA Valerio reminded Administrator to send the following annual documentation by 01/30/2025 to (916) 263 - 4747 or LPA Valerio: LIC500 – Personnel Report, LIC308 – Designation of Administrative Responsibility, LIC309 – Administration Organization, LIC610E – Emergency Disaster Plan, and copy of updated Liability Insurance Certificate.

Per California Code of Regulations (CCR) - Title 22 - no deficiencies are being cited on today's visit. 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: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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