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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200960
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:02:34 PM

Document Has Been Signed on 09/30/2021 02:02 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:HOLY ANGELS RESIDENTIAL FACILITYFACILITY NUMBER:
019200960
ADMINISTRATOR:RIVERA, ELENAFACILITY TYPE:
735
ADDRESS:25899 BEL AIRE DRTELEPHONE:
(510) 303-5317
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 0DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Elena Rivera, AdministratorTIME COMPLETED:
02:10 PM
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On 9/27/2021 starting at 12:10pm, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct an attempted Infection Control Inspection. LPA knocked and rang the doorbell multiple times and no answer. LPA spoked to Administrator, Elena Rivera over the phone at 12:20pm and Administrator stated facility is currently not vendorize by Regional Center of East Bay (RCEB) so she currently does not have clients.

On 9/30/2021 starting at 1:10pm LPA L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Elena Rivera and explained the purpose of the visit. Facility currently has no clients.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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