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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804200
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:26:02 PM

Document Has Been Signed on 01/15/2025 04:26 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ANGELS ASSISTED LIVING LLCFACILITY NUMBER:
496804200
ADMINISTRATOR/
DIRECTOR:		QUIJADA, CLAUDIAFACILITY TYPE:
740
ADDRESS:5525 CARRIAGE LANETELEPHONE:
(707) 791-3172
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 5CENSUS: 3DATE:
01/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Claudia Quijada-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a case management inspection, and met with Administrator Claudia Quijada.

The case management is being conducted to review a report of a resident AWOL. The LPA reviewed the incident with the Administrator, Administrator stated the resident R1 had left the facility out the front door without staff supervision. The staff on duty didn't hear the auditory alarm on the front door, and was unaware that R1 had left the facility. A Sheriff came to the facility regarding the resident R1 which a neighbor had called due to observing the resident wandering past their home. R1 was returned to the facility after the staff identified R1 as a resident of the care home. R1 was seen by paramedics that were called when the neighbor reported the resident was wandering in the neighborhood; R1 was assessed to have no injuries from the AWOL incident.

LPA obtained more information on resident incidents and death reports, including the AWOL reviewed above that were not reported to Licensing as required, per interview with the Administrator. In review of the incident, The staff failed to hear the auditory alarm on the exit door and the resident (R1) AWOL the facility without staff supervision.

This deficiency will be cited, 87705(d) Care of Persons with Dementia -The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, see LIC809D.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANGELS ASSISTED LIVING LLC
FACILITY NUMBER: 496804200
VISIT DATE: 01/15/2025
NARRATIVE
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Deficiency cited, 87211(a)(1)(2) Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D). This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Appeal rights given to the Administrator/Licensee.
Exit interview conducted with Administrator/Licensee Claudia Quijada.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/15/2025 04:26 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/15/2025 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ANGELS ASSISTED LIVING LLC
FACILITY NUMBER: 496804200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87705(d)

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87705(d) Care of Persons with Dementia -The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101,
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Licensee to ensure all exit door auditory alarms are working properly to ensure residents don't elope the facility without staff's knowledge and/or supervision. Hold an in-service training with all staff on dementia care plan regarding wandering, elopenment, and auditory alarms. Submit proof of training witth the staff. Submit plan of correction and proof of training by 1/31/25.
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This requirement was not met as evidenced by: Per LPA interiews LPA obtained more information on resident incidents and death reports, including the AWOL of R1 who left the facility without staffs knowledge. R1 was returned to the facility by the Sherriff who was called by a reporting neighbor. This is a risk to the health & safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/15/2025 04:26 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/15/2025 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ANGELS ASSISTED LIVING LLC
FACILITY NUMBER: 496804200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87211(a)(1)(2)

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87211(a)(1)(2) Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D).
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Licensee to ensure that all reports, incidents and deaths, that need to be submitted to licensing are completed as required and submitted within regulation time frame. Submit all reports, incidents/deaths as discussed during the inspection that were not received by Licensing Department. POC due 1/31/25.
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This requirement was not met as evidenced by: Based on interviews, review of incident/death reports, including an AWOL it was found that they were not reported as required. There have been resident reports that licensing should have been notified of. This is a risk to potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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