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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200390
Report Date: 07/20/2026
Date Signed: 07/20/2026 01:29:22 PM

Document Has Been Signed on 07/20/2026 01:29 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANGEL'S CREST HOME IIFACILITY NUMBER:
079200390
ADMINISTRATOR/
DIRECTOR:		MARIVIE FABIEFACILITY TYPE:
740
ADDRESS:1864 CAMINO RAMONTELEPHONE:
(707) 315-9664
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6CENSUS: 3DATE:
07/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Marivie FabieTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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On 7/20/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Leonida Arinzane and explained the purpose of the visit. Administrator arrived later during the visit at 11:10am. The facility’s fire clearance was approved for all may be non-ambulatory and a hospice waiver for 2.

LPA toured facility with caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 77 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were unlocked and accessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 8/13/2025. Emergency Disaster Plan was last reviewed on 7/30/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 5/1/2026.

LPA reviewed 3 of 3 residents records. LPA reviewed 3 staff records and 1 of 3 have current first aid training and 1 of 3 are associated to the facility.
Yvonne Flores-Larios
Alona Gomez
DATE: 07/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGEL'S CREST HOME II
FACILITY NUMBER: 079200390
VISIT DATE: 07/20/2026
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • LPA observed 2 individuals at the facility who are not associated (1 on shift and 1 in staff room; both stated they assist residents in care) no other staff present upon arrival
  • LPA observed unlocked sharps and chemicals in facility kitchen
  • LPA observed medications unlocked (med room unlocked/open and med cabinet also unlocked)
  • LPA observed facility is pre-pouring meds for R2 and not keeping them in their original container
  • S2 and S3 do not have files/training
  • R1-R3 files incomplete

** Civil Penalties assessed $1000 for 2 individuals not associated to the facility***

Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 8/01/2026:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

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.

Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2026 01:29 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/20/2026 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANGEL'S CREST HOME II
FACILITY NUMBER: 079200390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having unlocked cleaning chemicals and sharps in the kitchen which poses an immediate safety risk to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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2
3
4
By POC facility agrees to secure all dangerous items and notify CCLD.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 2 out of 3 individuals at the facility not being associated which poses an immediate personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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2
3
4
By POC facility agrees to associated S2 and S3 and notify CCLD (Civil Penalties Assesed)
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2026


LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/20/2026 01:29 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/20/2026 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANGEL'S CREST HOME II
FACILITY NUMBER: 079200390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in R1-R3 not having complete records (missing appraisals, signed personal rights, and or consent for emergency medical treatment) which poses a potential personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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By POC facility agrees to review residents records, up date them as necessary and notify CCLD.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 07/20/2026 01:29 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/20/2026 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANGEL'S CREST HOME II
FACILITY NUMBER: 079200390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in S2 and S3 not having any records or trainings for review which poses a potential personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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3
4
By POC facility agrees to update the personnel records and ensure all staff are up to date on training and notify CCLD
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 by having R2 medications prepoured into weekly medication containers which poses a potential personal rights risk to persons in care.
POC Due Date: 07/27/2026
Plan of Correction
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By POC facility agrees to provide a training on proper medication managment and dispenssing to all staff and provide copies of the training materials to CCLD
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 07/20/2026 01:29 PM - It Cannot Be Edited


Created By: Alona Gomez On 07/20/2026 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANGEL'S CREST HOME II
FACILITY NUMBER: 079200390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having medication cabinent unlocked which poses an immediate safety risk to persons in care.
POC Due Date: 07/21/2026
Plan of Correction
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2
3
4
By POC facility agrees to lock away all medications and notify CCLD
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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2026


LIC809 (FAS) - (06/04)
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