079200744-3-2-2022-15-AS-DPAO-CC5VFD-20220302152345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200744
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:25:02 PM

Document Has Been Signed on 03/02/2022 03:25 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:	ANGEL WINGS CARE HOME I		FACILITY NUMBER:	079200744
ADMINISTRATOR:	LOIDA PENA		FACILITY TYPE:	740
ADDRESS:	1403 PREWETT RANCH DRIVE		TELEPHONE:	(510) 329-4926
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 6	DATE:	03/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Loida Pena, Administrator		TIME 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 03/02/22 at 1:50PM, 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 with 3 residents watching TV while the other 3 residents were observed resting inside their bedrooms. Facility has a completed mitigation plan in place dated 04/01/2021 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. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, 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. 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: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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 I	FACILITY NUMBER: 079200744
	VISIT DATE: 03/02/2022

NARRATIVE

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A written Emergency/Disaster plan dated 01/01/22 was posted in a bulletin board next to the living room. Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers. Toxic chemicals were locked in the laundry room. LPA observed COVID signages posted outside of isolation room (Stop Droplet precautions & Proper donning & doffing of PPEs). Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Trash bins with lid operated with foot pedal were located inside bedrooms, bathrooms and kitchen.

Infection control designated leader is the administrator. All staff and residents have been fully vaccinated & boosted since October 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 74 degrees Fahrenheit. 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 observed fully charged. Smoke and Carbon monoxide detectors were operational.

LPA obtained copies of documents below from administrator:
· 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: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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