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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441151
Report Date: 01/27/2023
Date Signed: 01/27/2023 05:15:09 PM


Document Has Been Signed on 01/27/2023 05:15 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
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: 9DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Danilo "Sonny" Villar, Care StaffTIME COMPLETED:
05:30 PM
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On 01/27/23 at 04:05 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA was greeted by one care staff upon entry and explained the purpose of the visit. Designated Care Staff, Danilo "Sonny" Villar is available to sign the report.

Facility has a COVID-19 mitigation plan on file. LPA observed a screening station prior to entry that included COVID-19 signage, sanitizer, soap, paper towels, running water, thermometer and sign-in log at the entry. LPA toured the facility including, but not limited to common areas, bathrooms, kitchen, storage area and backyard. LPA observed masks, cough etiquette, social distancing and hand washing signs posted throughout. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. There is a surplus of PPE centrally located in the storage unit outside in the backyard and is accessible to all care staff. Hot water temperature in the shared residents' bathroom on the 1st floor was measured at 105.1 degree Fahrenheit (F) and the facility's temperature was 67 degree (F). Fire extinguisher was observed full and last inspected 03/22/2022. Smoke/Carbon Monoxide detectors were observed operational and directly connected to the fire department. First aid kit complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided to Care Staff, Danilo "Sonny" Villar
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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