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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 08/30/2024
Date Signed: 08/30/2024 04:13:11 PM


Document Has Been Signed on 08/30/2024 04:13 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: 5DATE:
08/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Wilfredo Bacani, CaregiverTIME COMPLETED:
04:30 PM
NARRATIVE
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On 8/30/2024 at 03:10pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Wilfredo Bacani, Caregiver.

While LPA L. Hall was conducting a complaint investigation 15-AS-20240826114945 on 8/30/2024, LPA observed the following during visit:
  • Residents do not have mattress pads, top sheets, and some do not have bedspreads. LPA observed two (2) clean face towels, no hand towels, and three (3) bath towels.
  • LPA observed unlocked kitchen drawer containing knives.
  • LPA observed S3 file was not available for review.


Facility will be assessed at $250.00 civil penalty for a repeat violation for 87705(f)(1).

Deficiencies are 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.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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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Document Has Been Signed on 08/30/2024 04:13 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: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87307(3)(C)

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(3) ...supplies necessary for personal care and maintenance... shall be readily available to each resident. ...if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall... at least once per week or more often...
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Administrator agreed to purchase additonal linen including towels and submit receipt and photo of new items to CCLD by POC date.
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This requirement was not met as evidence by:
Based on observation the Licensee did not comply with the section cited above in having sufficent linen for residents, which poses a possible health and safety risk to persons in care.
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Type B
09/06/2024
Section Cited
CCR87412(f)

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87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidence by:
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Administrator agreed to have S3's file readily for review at facility ad submit a self certification to CCLD by POC date.
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Based on observation and record review the Licensee did not comply with the section cited above in having S3's file available for review, which poses a potential 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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/30/2024 04:13 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: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2024
Section Cited
CCR
87705(f)(1)

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87705 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 was not met as evidence by:
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Caregiver locked kitchen drawer containing knives. Deficiecency cleared.
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Based on observation the Licensee did not comply with the section cited above in having knives locked and inacessible to residents, which poses a 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: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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