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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920117
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:59:43 PM

Document Has Been Signed on 12/19/2024 03:59 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:RAI ANGELSFACILITY NUMBER:
345920117
ADMINISTRATOR/
DIRECTOR:		RAI, BALWINDERFACILITY TYPE:
740
ADDRESS:6613 TRILBY CT.TELEPHONE:
(916) 945-2122
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 4DATE:
12/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Balwinder Rai, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a case management inspection related to a waiver request submitted to the Department on 12/18/24. LPA met with Balwinder Rai, Administrator, and stated reason for the inspection.

During today's inspection, LPA and the Administrator discussed the current residents and their care needs, including if any resident needs a two-person transfer. The Administrator indicated that there are always (2) staff on site at all times to provide care when needed.

Also discussed was how the waiver request was submitted, in error, for a resident (R1) who already lives at the facility, and the request should be for a potential resident (R2) who has not moved in yet. LPA obtained an updated waiver request as well as a current physician's report for (R2) noting the diagnoses.

LPA confirmed there are currently (4) residents living in the home and (1) resident is expected to return from skilled nursing by end of this month. The waiver is needed since there is currently (1) resident (R1) who is under the age of 60 years.

LPA to provide paperwork obtained today to LPM for review. LPA to follow up with Administrator as soon as possible, by tomorrow, 12/20/24, if possible.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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