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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 02/22/2024
Date Signed: 02/22/2024 07:21:23 PM


Document Has Been Signed on 02/22/2024 07:21 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 CARE HOMEFACILITY NUMBER:
079201134
ADMINISTRATOR:WANG, DINGFACILITY TYPE:
740
ADDRESS:1723 LIMEWOOD PLACETELEPHONE:
(925) 635-3936
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 3DATE:
02/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lester Bacani, CaregiverTIME COMPLETED:
07:35 PM
NARRATIVE
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On 2/22/2024, at 2:45PM, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct proof of correction (POC) visit. LPAs met with Lester Bacani, Caregiver, and explained the purpose of the visit. Administrator, Ding Wang, arrived at 3:55pm.

Facility had the following deficiencies cited on 2/13/2024 and has not been cleared as of today's date.

  • 87202(a)(1), LPAs observed residents are in the same room as the visit on 2/13/2024. Facility still in violation of fire clearance.
  • 87211(a)(1), LPAs did not receive any incident reports or death reports from Administrator.
  • 87632(d), LPAs did not receive hospice notifications from Administrator.
  • 87465(h), LPAs observed MAR for each resident is still not aligned with medication.
  • 87506(a), LPAs observed resident files were not completed
  • 87411(c), LPAs observed facility staff does not have any training but LPAs approved extension until 3/4/2024.


Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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


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 CARE HOME
FACILITY NUMBER: 079201134
VISIT DATE: 02/22/2024
NARRATIVE
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Continued from LIC809.

LPAs observed the following deficiency today:
  • At 2:50pm, LPAs observed that S5 has not been fingerprinted or associated to facility.

LPAs observed the following deficiencies that were cited on 2/13/2024 has been cleared.
  • 87412(a), LPAs observed personnel files have been completed
  • 87355(d)(3) - LPAs observed S3 will not work here.
  • 87303(e) - LPAs observed Caregiver adjusted hot water temperature and it now measures between 105 - 120 degrees F.
  • 87405(a) - LPAs had administrator read regulation during today's visit.
  • 87555(b)(26) - LPAs observed administrator purchased food.

Civil Penalties in the total amount of $2,200.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/22/2024 07:21 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: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87355(d)(3)

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87355 (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... (3) The licensee shall submit these fingerprints... for the purpose of searching the records... prior to the individual's employment, residence, or initial presence in the facility. This requirement was not met as evidence by:
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Administrator agreed to get S5 fingerprinted and submit proof to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having S3 fingerprinted before working at facility which poses a potential immediate health and safety risk to persons in care.
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3