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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200960
Report Date: 09/05/2024
Date Signed: 09/06/2024 12:29:40 PM

Document Has Been Signed on 09/06/2024 12:29 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/
DIRECTOR:		RIVERA, ELENAFACILITY TYPE:
735
ADDRESS:25899 BEL AIRE DRTELEPHONE:
(510) 303-5317
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 3DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Elena Rivera, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 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 9/5/24 at 9:33AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection. LPA rang doorbell no one answer. LPA observed there are no one at the facility. LPA later got in touch with Administrator (AD), Elena Rivera and explained the purpose of the visit. AD stated that all clients are at day program and AD had an emergency that cannot be available. LPA explained that LPA will try another attempt at another time.

On 9/06/24 at 10:00AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a continuation annual required inspection. LPA was greeting by Direct Support Professional, Marissa Fernandez. LPA explained the purpose of the visit. Administrator (ADM), Elena Rivera later arrived. Administrator Certification number 6052968735 expire on 2/17/2025.

At 11AM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms, and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas.
Medication was locked in the cabinet. Toxic chemicals were stored and locked in storage shed.
Fire Drill was conducted on 8/8/24. Fire extinguisher last service on 3/28/2024.

At 11:30AM, LPA observed facility has a sufficient 2-day perishable and 7-day non-perishable food supply.
At 11:45AM LPA sample client’s medication.

Report continued on LIC 809c...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 2
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: HOLY ANGELS RESIDENTIAL FACILITY
FACILITY NUMBER: 019200960
VISIT DATE: 09/05/2024
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
Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 117.7 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. P&I money were observed separate from facility funds and matched record logs. LPA reviewed 2 staff and 3 client files. LPA observed that there is no client at the facility during visit.

No deficiency issue on today date. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2