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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701044
Report Date: 05/06/2024
Date Signed: 05/06/2024 11:59:21 AM

Document Has Been Signed on 05/06/2024 11:59 AM - 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:ANGEL'S CARING HANDFACILITY NUMBER:
502701044
ADMINISTRATOR/
DIRECTOR:		ANTONIO, MA TABITHAFACILITY TYPE:
740
ADDRESS:3709 COYE OAK DRTELEPHONE:
(209) 312-9880
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Tabitha AntonioTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 05/06/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member, Dodie Aguilucho and explained the purpose of the visit. LPA asked for SM Aguilucho to contact the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. There was one other staff member present, Mater Panaligan. Shortly after, LPA met with FDA Tabitha Antonio and explained the purpose of this visit.

Current Census was 6. A brief interview with FDA Antonio was conducted.
This facility is licensed to serve 6 elderly residents of which all may be non-ambulatory. This facility also holds a dementia plan on file.
LPA reviewed 6 resident files and 4 staff files. All files were current and up to date. The administrator has an expired administrator certificate however the LPA was able to verify that the administrator was able to send in the required documents prior to their expiration. The administrator is currently awaiting the department for a renewed certificate.
A tour of the facility was conducted.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co on 01/19/2024. Smoke Detector and carbon monoxide was observed to be in good repair.
The kitchen area was toured. LPA observed a 7 day non-perishable and 2 perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.
LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ANGEL'S CARING HAND
FACILITY NUMBER: 502701044
VISIT DATE: 05/06/2024
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability insurance

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to the facility.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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