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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201319
Report Date: 05/02/2024
Date Signed: 06/12/2024 02:58:27 PM


Document Has Been Signed on 06/12/2024 02:58 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/11/2024 04:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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This is an amended report. On this day, 06/12/2024, Licensing Program Analysts (LPAs), L. Alexander and L. Holmes returned to correct the deficiencies that were cited on the Pre-Licensing report but should have been cited on the current facility license #11441151.

On 05/02/2024 at 9:45 AM, Licensing Program Analysts (LPAs) Lori Alexander and Lisha Holmes arrived unannounced to conduct Pre-Licensing inspection. LPAs met with Caregiver, Danilo "Sonny" Villar and explained the purpose of the visit. Sonny phoned the Licensee/Administrator, Richard De Leon to inform. LPAs spoke with Richard over the phone and Richard stated that he would not be available to come to the facility for the inspection. The facility currently has ten (10) residents. Administrator Certificate #6024437740 expires 02/02/2027.

LPAs toured facility with Sonny including but not limited to twelve (12) bedrooms, five (5) bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 68 degrees F. and hot water temperatures was measured at 105.4 degrees downstairs and 111.5 degrees F. upstairs. LPAs observed 2 days supply of perishable and one week supply of non-perishable foods. First-aid kit was observed to be incomplete. Emergency Disaster Plan, contact information and personal rights were observed posted in common areas. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 03/12/2024.


LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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 6


Document Has Been Signed on 06/12/2024 02:59 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/11/2024 04:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANGELEON CARE HOME
FACILITY NUMBER: 019201319

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not having training records available for Administrator and Care Staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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Administrator to submit a copy of all updated training to CCLD by POC due date.
Type B
Section Cited
CCR
87465(a)(8)
87465 Incidental Medical and Dental Care

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in by not having a complete First Aid kit with a manual of instructions which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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Administrator to purchase a new First Aid kit and submit photo to CCLD by POC due date.
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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGELEON CARE HOME
FACILITY NUMBER: 019201319
VISIT DATE: 05/02/2024
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LIC809-C Continued...

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

LPAs observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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