019200531-9-18-2024-15-AS-LHOS-D98SK8-20240918135618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200531
Report Date: 09/18/2024
Date Signed: 09/18/2024 01:59:17 PM

Document Has Been Signed on 09/18/2024 01:59 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:	ANGELS WINDSOR HOUSE		FACILITY NUMBER:	019200531
ADMINISTRATOR:	HAIDIE BAUTISTA		FACILITY TYPE:	740
ADDRESS:	2741 HILLEGASS AVENUE		TELEPHONE:	(510) 845-1850
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94705
CAPACITY:	15	CENSUS: 14	DATE:	09/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Haidie Bautista, Administrator		TIME COMPLETED:	02:15 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	On 09/18/24 at 10:20 AM, Licensing Program Analysts (LPAs) L. Holmes and Patricia Manalo arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Haidie Bautista, Administrator (ADM) was telephoned by the staff member and arrived about 5 minutes later. Facility has a COVID-19 mitigation plan, ICP & EDP on file. LPAs reviewed the resident roster, staff roster and Emergency Disaster Plan. Facility continues to screen for COVID, has hand sanitizer, COVID-19 signage, and a visitor sign-in log. LPAs toured the facility including, but not limited to common areas, bathroom, kitchen, front and side pathways. LPAs observed mask, 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 and covered garbage cans. ADM to add paper towels to shared bathroom. There is a surplus of PPE stored centrally located inside the facility that is accessible to all care staff. The facility's temperature was 68 degrees (F) and water in shared bathroom was 109.4. Fire extinguisher was observed full and expires 11/15/24. Smoke/Carbon Monoxide detectors were observed operational and 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) -LIC610 Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate(s) (Reviewed) Continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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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Document Has Been Signed on 09/18/2024 01:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGELS WINDSOR HOUSE	FACILITY NUMBER: 019200531
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not comply with the section cited above by not providing window screens in the kitchen, bedrooms and common areas which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Licensee to update CCLD with a quote and provide photos when the screens are installed on or before POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGELS WINDSOR HOUSE	FACILITY NUMBER: 019200531
	VISIT DATE: 09/18/2024

NARRATIVE

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...continued from LIC809

-At 12:55 PM, LPAs observed the kitchen, bedroom and common areas did not have window screens attached; bedroom #1, 2, 3, 8 & 9.

Based on observation, deficiency are cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided to Haidie Bautista, Administrator (ADM)

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC809 (FAS) - (06/04)

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