079201134-4-30-2024-15-AS-LHAL-D4U3UC-20240430183320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 04/30/2024
Date Signed: 04/30/2024 06:33:48 PM

Document Has Been Signed on 04/30/2024 06:33 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 HOME		FACILITY NUMBER:	079201134
ADMINISTRATOR:	WANG, DING		FACILITY TYPE:	740
ADDRESS:	1723 LIMEWOOD PLACE		TELEPHONE:	(925) 635-3936
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94553
CAPACITY:	6	CENSUS: 5	DATE:	04/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mary Lorraine Adriatico, Caregiver		TIME COMPLETED:	04:40 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 4/30/2024 at 10:30am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Mary Lorraine Adriatico, Caregiver, and explained the purpose of the visit. Ding Wang, Administrator arrived at 11:05am. The facility’s fire clearance was approved for four (4) ambulatory, one (1) non-ambulatory, and one (1) bedridden resident. Facility has a hospice waiver for two (2). LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms two one-half (2-1/2) bathrooms. LPA observed pool in the backyard has locked gate. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 100.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 04/24/2024. Emergency Disaster Plan was last posted on 9/1/2023. First aid kit was observed to be complete. Continued on LIC809.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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 CARE HOME	FACILITY NUMBER: 079201134
	VISIT DATE: 04/30/2024

NARRATIVE

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Continued from LIC809.

LPA reviewed four (4) staff files. All five (5) residents' file were reviewed and a sample of resident's medication.

LPA observed the following deficiencies:

At 11:45am, LPA observed Comet can powder, Comet spray disinfectant in unlocked cabinet underneath kitchen sink.
At 11:45am, LPA observed knives and scissors in unlocked drawer next to stove.
At 12:00pm, LPA observed bathroom disinfectants and fabuloso in unlocked shared bathroom cabinet underneath sink.
At 12:03pm, LPA observed R5 in a non-ambulatory room.
At 12:05pm, LPA observed Comet underneath sink and toilet cleaner tablets in unlocked drawer in master bathroom.
At 2:10pm, LPA observed closet doors, bed rails, shower doors, wooden planks, 2 wheelchairs, 2 walkers, and 3 commodes located on right side of facility in back yard.
At 12:25pm, LPA observed facility has hospice waiver for two (2), but have three (3) hospice residents.
At 3:00pm, LPA observed Administrator did not have a current administrator certificate.
At 3:15pm, LPA observed R4 with full-bed rail and no doctor's order.

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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 CARE HOME	FACILITY NUMBER: 079201134
	VISIT DATE: 04/30/2024

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Continued from LIC809C.

LPA requested the following documents to be submitted to CCLD by 5/7/2024.

Resident Roster
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate civil penalty of $500.00 for two (2) repeat violations will be assessed on today's date*

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2024 06:33 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having cleaning supplies accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Caregiver immediately locked away disinfectants in garage. Deficiency cleared during visit.

Type A

Section Cited

CCR

87405(a)

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having an administrator employed at facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Administrator agreed to implement plan or submit documents showing recertification to CCLD by POC date.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2024 06:33 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87633(a)(2)

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having only 2 residents residing in facility on hospice which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Administrator will implement a plan to accommodate more than two (2) hospice residents, and submit plan to CCLD by POC date.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2024 06:33 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(c)(1)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a resident with dementia in a ambulatory room only per fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Administrator will implement a plan to have R4 in correct room and submit plan to CCLD by POC date.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(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). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having knives and scissors inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Caregivers immediately locked knives and scissors in drawer. Deficiency cleared during visit.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2024 06:33 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a full bedrail for R4 and no doctor's order which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2024
	Plan of Correction
1 2 3 4	Administrator will obtain order for full bedrail and submit copy to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation], the licensee did not comply with the section cited above in having outdoor passageways clear of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/07/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have all items removed and submit photos to CCLD by POC date.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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