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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201339
Report Date: 03/28/2024
Date Signed: 03/28/2024 04:03:37 PM

Document Has Been Signed on 03/28/2024 04:03 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 FACILITY 2FACILITY NUMBER:
019201339
ADMINISTRATOR:RIVERA, ELENA H.FACILITY TYPE:
735
ADDRESS:25874 BEL AIRE DRIVETELEPHONE:
(510) 303-5317
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 0DATE:
03/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Elena Rivera, AdminstratorTIME COMPLETED:
03:30 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 3/28/24 at 2:45 PM, Licensing Program Analyst (LPA) Greg Clark arrived announced to conduct pre-licensing inspection. LPA met with Administrator, Elena Rivera and explained the purpose of the visit. The facility currently has no residents/clients.

LPA toured facility including but not limited to bedrooms, 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 70 degrees F. Hot water temperature at the kitchen sink was measured at 125.8 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 3/28/24.

Prior to licensure, the following shall be corrected and emailed to CCL by 3/29/24.

Hot water temperature not to exceed regulation (105 - 120 degrees F). Proof of correction to sent to LPA by POC date.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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 1