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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200994
Report Date: 12/09/2022
Date Signed: 12/09/2022 02:11:51 PM


Document Has Been Signed on 12/09/2022 02:11 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:ANGELS TOUCH CARE HOME, LLCFACILITY NUMBER:
079200994
ADMINISTRATOR:ROSS, LARUTHFACILITY TYPE:
740
ADDRESS:1653 SWALLOW WAYTELEPHONE:
(510) 725-2020
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 4DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Raejael Morning, caregiverTIME COMPLETED:
02:20 PM
NARRATIVE
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On 12/09/2022 at 11:50 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Raejael Morning and explained the purpose of the visit.
Administrator arrived at 12:15pm.

Upon entry, LPA temperature was checked. LPA observed screening station that contained hand sanitizer, masks and COVID-19 signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters. observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan on file.

During the tour the following deficiency was observed:
  • At 12:22 PM LPA observed the garage door unlocked which contained chemicals such as Ajax, Pine Sol, Windex, Fabuloso, laundry soap Ultra Clean, Clorox Bleach, oxy clean.
  • At 12:24 PM LPA observed a room in the garage not on facility sketch that contained a mattress with sheets, covers and pillow and a caregiver.
  • At 12:28 PM LPA observed an unlocked shed located in the back yard which contained tools such as a ladder, paint, rake, shovel and chemicals.
  • At 12:30 PM LPA observed OTC medications such as vitamins C powder and other supplements.
  • At 12:32 PM LPA observed a fire extinguisher without a service tag.

Continued on LIC809D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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 12/09/2022 02:11 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: ANGELS TOUCH CARE HOME, LLC
FACILITY NUMBER: 079200994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 chemicals such as Ajax, Pine Sol, Windex, Fabuloso, Laundry soap Ultra Clean, ladder, paint rake shovel, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/10/2022
Plan of Correction
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Administrator agreed to lock garage door, and put a lock on the shed and send photos to CCLD no later then the POC date.
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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/09/2022 02:11 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: ANGELS TOUCH CARE HOME, LLC
FACILITY NUMBER: 079200994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety:

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above by not having a service tag or receipt of date fire extinguisher was serviced, which poses a potential health and safety risk for persons in care.
POC Due Date: 12/27/2022
Plan of Correction
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Administrator agreed to provide CCLD with a photo copy of receipt when fire extinguisher was serviced no later then the POC date.
Type B
Section Cited
CCR
87208(A)
Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7) Sketches, showing dimensions, of the following: This requirement was not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation licensee did not comply with the section cited above by having a possible unpermitted room not on facility sketch in the garage which contains a mattress with sheets, blankets and a pillow being used for accommodation. Which poses a potential health and safety risk to residents in care .
POC Due Date: 01/06/2023
Plan of Correction
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Administrator agreed to provide a permit for room located in garage, and not allow staff to use the room for dwelling.
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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3