<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003013
Report Date: 10/07/2026
Date Signed: 10/07/2026 03:06:53 PM

Document Has Been Signed on 10/07/2026 03:06 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:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR/
DIRECTOR:		BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT OAK DRIVETELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 4DATE:
10/07/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:09 AM
MET WITH:Simranjit BhatiaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit regarding deficiencies observed. LPA met with Administrator and explained the purpose of the visit. This was a joint visit with Fire Inspector, Laura Bell, with Roseville Fire Department who reviewed facility's fire compliance.

On September 14, 2026, a visit was made regarding resident (R1)’s death. Based on the Placer County Sheriff Coroner’s Report, it stated that staff became aware that R1 was breathing abnormally at 9:30 am. R1 was then unresponsive at 10:30 am. A file review of the City of Roseville incident report, it revealed that 911 was not contacted until 11:12 am by R1’s responsible party when they arrived to the facility.

On September 24, 2026, a joint visit was conducted by LPAs Cassie Yang and Graham Gunby, and Licensing Program Manager (LPM) Troy Ordonez. During this visit, LPM was informed about staff (S1)’s performance as a caregiver. File review of S1’s fingerprint clearance revealed that S1 does not have a criminal record clearance, as an exemption is needed. An interview was conducted, which confirmed that S1 worked at the facility on September 17, 2026, and September 21, 2026.

During LPA’s previous visits conducted on September 10, 2026, and September 14, 2026, it was observed that resident (R2) was residing in Bedroom #3. A file review of the facility’s facility sketch and approved STD 850 was later conducted at the regional office. It revealed that R2 has been residing in the designated staff room. A file review of R2’s physician's order from June 1, 2026, it confirmed that R2 has dementia. The staff room does not have a non-ambulatory fire clearance.

Please continue on LIC 809-C
Troy Ordonez
Cassie Yang
DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
VISIT DATE: 10/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LIC 809-C

Additional file review was conducted, which revealed that R2 was sent to the emergency room for medical evaluation due to their behavior. A file review of the City of Roseville incident report, it revealed that 911 was contacted regarding R2’s “dementia episode”. Administrator then informed local law enforcement that R2 is not welcome back to the facility after the hospital visit. Administrator confirmed that a 30-day eviction was not provided.

It was discussed that facility staff has been administering liquid morphine oral concentrate, lorazepam oral concentrate and haloperidol oral concentrate to resident (R3) who is on hospice services. LPA was informed that R3 is not capable of self-administration. LPA explained to Administrator that staff are only able to assist with self-administration. If a resident cannot administer their own medications then it is to be discussed with resident's primary care physician.

As a result of today’s visit, deficiencies cited and civil penalties assessed. Please see LIC 809-D.

Exit interview conducted, and a copy of the report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/07/2026 03:06 PM - It Cannot Be Edited


Created By: Cassie Yang On 10/07/2026 at 01:32 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2026
Section Cited
CCR
87202(a)(1)

1
2
3
4
5
6
7
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… (1) Nonambulatory persons.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
- Bedroom #3 has since been vacant.
- Licensee is to submit a letter to acknowledge that no residents in care can reside in Bedroom #3 until a new fire clearance is completed. Letter is due to Licensing on October 8, 2026.
8
9
10
11
12
13
14
Based on file review and observation, Licensee did not comply with the section cited above, as Licensee had a resident with dementia, residing in a room that does not have a non-ambulatory clearance which poses an immediate health and safety risk for residents in care.
8
9
10
11
12
13
14
Type A
10/08/2026
Section Cited
CCR87411(g)(3)

1
2
3
4
5
6
7
87411 Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (3) Request and be approved for a transfer of a criminal record exemption… This requirement is not met as evidenced by:
1
2
3
4
5
6
7
- S1 cannot work at the facility until exemption is approved.
- Licensee is to submit staff schedule for October 1-15, 2026. Staff schedule is due to Licensing on October 8, 2026.
8
9
10
11
12
13
14
Based on interviews conducted, Licensee did not comply with the section cited above as Licensee had S1 working at the facility for two days without a granted criminal record exemption which poses an immediate health and safety risk for residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/07/2026 03:06 PM - It Cannot Be Edited


Created By: Cassie Yang On 10/07/2026 at 01:48 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2026
Section Cited
CCR
87465(a)(1)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
- Licensee is to create an emergency and response plan for staff to ensure they know who and when to contact medical services. This plan is due to Licensing by October 8, 2026.
8
9
10
11
12
13
14
Based on interviews and file reviews, Licensee did not comply with the section cited above, as it was observed that R1 was declining, but facility staff failed to contact emergency medical services immediately which poses an immediate health and safety risk for residents in care.
8
9
10
11
12
13
14
Type A
10/08/2026
Section Cited
CCR87465(a)(5)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
- Licensee contacted R3's hospice agency immediately regarding being unable to administer medications.
- Licensee is to submit a plan to Licensinng of how medications will be administered to resident as R3 is unable to self-administered.
This plan is due October 8, 2026 to Licensing.
8
9
10
11
12
13
14
Based on interview and file review, Licensee did not comply to the section cited above as facility staff has been administering liquid morphine, lorazepam, and haloperidol to R3 who cannot assist with the self-administration, which poses an immediate risk for residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/07/2026 03:06 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Cassie Yang On 10/07/2026 at 01:58 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
10/30/2026
Section Cited
CCR
87224(a)

1
2
3
4
5
6
7
87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required… This requirement is not met as evidenced by:
1
2
3
4
5
6
7
- A 30-day eviction letter is to be issued to R2 and R2's responsible party. A copy is to be provided to Licensing. This plan of correction is due to Licensing on October 30, 2026.
8
9
10
11
12
13
14
Based on interview and file review, Licensee did not comply with the section cited above, as R2 was sent to the emergency room for evaluation when Administrator informed emergency medical services that R2 is not allowed back to the facility after hospital visit without an effective 30-day eviction notice, which poses a potential health and safety risk for residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Ordonez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6