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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200744
Report Date: 02/06/2025
Date Signed: 02/06/2025 02:24:12 PM

Document Has Been Signed on 02/06/2025 02:24 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 IFACILITY NUMBER:
079200744
ADMINISTRATOR/
DIRECTOR:		ROSE ANCHOLONUFACILITY TYPE:
740
ADDRESS:1403 PREWETT RANCH DRIVETELEPHONE:
(925) 706-2149
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Aicha Sacko, Caregiver
Rose Ancholonu, Administrator		TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 02/06/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and explained the purpose of the visit. LPA spoke with ADM on the phone who authorized S1 to act on her behalf and sign the reports. LPA observed ADM has a current administrator certificate# 6056379740 which expires 09/26/2027.

At 12:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas.

Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 68 deg F. Hot water temperature was measured at 112 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Smoke and Carbon monoxide detectors were operational. LPA reviewed 3 resident files. LPA did not have access to staff files because caregiver did not have the key to open the staff files cabinet.

Continued on next page, LIC 809-C
Bennett FongTELEPHONE: (510) 622-2621
Daisy PanlilioTELEPHONE: (510) 286-4201
DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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: 02/06/2025
NARRATIVE
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The following deficiencies were observed during visit:
  • Outside pathway leading to side gate obstructed by old mattress left leaning against facility side wall.
  • Disorganized and incomplete resident files - missing appraisal reports
  • Inaccessible staff files - staff does not have the key to open cabinet where staff files are kept


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/06/2025 02:24 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 02/06/2025 at 01:34 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 WINGS CARE HOME I
FACILITY NUMBER: 079200744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)


This requirement is not met as evidenced by: All outdoor and indoor passageways and stairways shall be kept free of obstruction.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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By POC due date, Administrator agrees to remove old mattress from outside pathway and submit a photo of cleared area to CCL in compliance with Section 87307 (d)(6) regulation.
Type B
Section Cited
CCR
87463(a)


This requirement is not met as evidenced by: The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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By POC due date, Administrator agrees to complete/update each resident's appraisal report and submit proof of correction to CCL in compliance with Section 87463 (a) regulations.
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:Bennett Fong
TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME:Daisy Panlilio
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/06/2025 02:24 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 02/06/2025 at 01:57 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 WINGS CARE HOME I
FACILITY NUMBER: 079200744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)


This requirement is not met as evidenced by: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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By POC due date, Administrator agrees to have staff files accessible for inspection at the facility in compliance with Section 87412 (f) regulations.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME:Daisy Panlilio
TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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