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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200761
Report Date: 12/16/2022
Date Signed: 12/16/2022 05:04:45 PM


Document Has Been Signed on 12/16/2022 05:04 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:HOLY ANGEL HOME CARE 1FACILITY NUMBER:
079200761
ADMINISTRATOR:LIU, ALEXANDRIAFACILITY TYPE:
740
ADDRESS:1359 SUNFLOWER LANETELEPHONE:
(925) 626-3861
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 3DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:ALEXANDRIA LUI, Administrator TIME COMPLETED:
05:20 PM
NARRATIVE
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On 12/16/2022, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and met with Administrator Alexandia Lui, LPA explained the purpose of the visit. Facility has a completed mitigation plan and copy of infection control plan was received. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 71 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.
Facility completed the additional room adjacent to the front door. LPA was notified on 11/20/2022. There was no capacity increase, licensee just added a room. City inspection was completed 12/16/2022.

LPA observed the following:
· Unlocked medications accessible to residents in care
· Bedroom #3’s closet is being utilized as facility’s storage, staff use bedroom #3 as passageway

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Alexandria Lui, Administrator.



Exit interview conducted and appeal rights copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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 3


Document Has Been Signed on 12/16/2022 05:04 PM - It Cannot Be Edited

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: HOLY ANGEL HOME CARE 1
FACILITY NUMBER: 079200761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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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Based on observation, the licensee did not comply with the section cited above by having unlocked medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Staff locked medications during inspection.
Deficiency cleared during inspection.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/16/2022 05:04 PM - It Cannot Be Edited

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: HOLY ANGEL HOME CARE 1
FACILITY NUMBER: 079200761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(C)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function....The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.


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 using bedroom #3’s closet being use as facility storage, staff was using bedroom #3 as passageway to access this storage which poses a potential personal rights violation to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
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Administrator stated she will send a sketch stating that closet is for storage and bathroom is staff only. Staff needs to use outside door and not use bedroom #3 as passageway.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3