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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441151
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:31:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANGELEON CARE HOMEFACILITY NUMBER:
011441151
ADMINISTRATOR:DE LEON, RICHARDFACILITY TYPE:
740
ADDRESS:2124 ASHBY AVENUETELEPHONE:
(510) 704-8319
CITY:BERKELEYSTATE: CAZIP CODE:
94705
CAPACITY:12CENSUS: 11DATE:
09/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Danilo Villar, caregiverTIME COMPLETED:
02:45 PM
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On 09/29/21 at 2:16PM, Licensing Program Analysts (LPAs) Daisy Panlilio and Lisha Holmes conducted an unannounced case management during the complaint visit and met with administrator (ADM). LPAs explained the purpose of the visit with ADM.

LPAs discussed with ADM the Provider Information Notice (PIN) # 21-40-ASC which clearly describes visits from CDSS, CDPH, CDDS or local regional center, local health department officials, mental/healthcare providers are exempt from vaccination verifications when visiting the facility on official business. S1 stated he will comply with this PIN and train staff to receive essential workers without requesting vaccination verification when conducting official business at the facility.

Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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