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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200535
Report Date: 04/27/2022
Date Signed: 04/27/2022 11:01:17 AM

Document Has Been Signed on 04/27/2022 11:01 AM - 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:JOANGEL HAVENFACILITY NUMBER:
079200535
ADMINISTRATOR:SAN MATEO, JOSEFINA AFACILITY TYPE:
735
ADDRESS:4895 THIESSEN COURTTELEPHONE:
(925) 285-6411
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 4DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH: Josefina San Mateo, AdministratorTIME COMPLETED:
11:08 AM
NARRATIVE
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On 04/27/2022 at 8:42 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Administrator Josefina San Mateo and explained the purpose of the visit.

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. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 02/14/2022.

The following deficiency was observed during the visit:
LPA observed/interviewed staff that they are using bedroom 3 as a passageway to a bathroom 1
LPA observed that there is not a seven day supply of non-perishables at the facility
LPA observed laundry soap was observed being stored on the same shelf as food in the garage
LPA observed staffs prescription mouth wash was left in the bathroom accessible to the clients
LPA observed the following areas/items unlocked; outdoor shed, pick axe, laundry chemical storage, chemicals under kitchen sink, and chemicals under sink in bathroom 3.


The Facility was cited and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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 4
Document Has Been Signed on 04/27/2022 11:01 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/27/2022 at 10:12 AM
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: JOANGEL HAVEN
FACILITY NUMBER: 079200535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in five counts (outdoor shed unlocked, pick axe left out, laundry chemical storage unlocked, chemicals under kitchen sink unlocked, cleaner under sink in bathroom 3 unlocked) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Cleared during visit
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

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 by having staffs perscription mouth was left in bathroom 2 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2022
Plan of Correction
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4
POC cleared during visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/27/2022 11:01 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/27/2022 at 10:12 AM
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: JOANGEL HAVEN
FACILITY NUMBER: 079200535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(4)
Building and Grounds
(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and interview, the licensee did not comply with the section cited above by allowing the staff to use bathroom 1 which is located in Client bedroom 3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2022
Plan of Correction
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POC cleared during visit.
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 a bottle of laundry soap stored on the same shelf as food in the garage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2022
Plan of Correction
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2
3
4
POC cleared during visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/27/2022 11:01 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/27/2022 at 10:12 AM
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: JOANGEL HAVEN
FACILITY NUMBER: 079200535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by not having a one week nonperishable supply of food at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Facility will buy more canned/dried food. receipt or photo of food supply will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
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