079200743-1-7-2022-15-AS-DPAO-CAG2FG-20220107162130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200743
Report Date: 01/07/2022
Date Signed: 01/07/2022 04:24:19 PM

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:	ANGEL WINGS CARE HOME II		FACILITY NUMBER:	079200743
ADMINISTRATOR:	SAMIA, VILMA		FACILITY TYPE:	740
ADDRESS:	1921 BLUE MOUNTAIN COURT		TELEPHONE:	(510) 329-4926
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 4	DATE:	01/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Versan Ibat, Administrator		TIME COMPLETED:	04:50 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 01/07/22 at 03:10PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 2 staff wearing face masks during visit. LPA observed 4 residents watching TV during visit. Facility has a mitigation plan in place dated 01/04/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. A written Emergency/Disaster plan dated 01/04/22 was posted near a Lan line phone in the office. Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers.Toxic chemicals were locked in the garage. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGEL WINGS CARE HOME II	FACILITY NUMBER: 079200743
	VISIT DATE: 01/07/2022

NARRATIVE

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Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since November 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the pantry. Facility room temperature was maintained at 70 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. Administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was fully charged and last inspected on 04/15/2021. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the garage. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. The facility has auditory signals on each sliding door in the resident's room for exit.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/10/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022

LIC809 (FAS) - (06/04)

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