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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 06/05/2025
Date Signed: 06/05/2025 06:19:45 PM

Document Has Been Signed on 06/05/2025 06:19 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/
DIRECTOR:		WANG, DINGFACILITY TYPE:
740
ADDRESS:1723 LIMEWOOD PLACETELEPHONE:
(925) 635-3936
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY: 6CENSUS: 6DATE:
06/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Laly Bascao, CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 6/5/2025 at 1:45pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year required inspection. LPA met with Laly Bascao, Caregiver, Caregiver, and explained the purpose of the visit. The facility’s fire clearance was approved for four (4) ambulatory, two (2) non-ambulatory, of which one may be a bedridden resident. Facility has a hospice waiver for two (2).

LPA toured the facility with Caregiver 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 73 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 99.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 11/23/2024. Emergency Disaster Plan was last reviewed on 5/1/2025. First aid kit was observed to be complete.

Continued on LIC809.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 06/05/2025
NARRATIVE
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Continued from LIC809.

LPA reviewed five (5) staff and all six (6) resident records. LPA reviewed a sample of three (3) residents' medication.

LPA observed the following deficiencies:
  • At 2:15pm, LPA observed during record review there was not any training conducted by staff.
  • At 2:50pm, LPA observed R6 did not have dresser/chest of drawers in the bedroom, R1 did not have a dresser/chest of drawers in the bedroom, and R2 did not have a night stand or lamp in the bedroom.
  • At 3:00pm, LPA observed facility has one (1) bedridden, five (5) total non-ambulatory, and one (1) ambulatory resident, which does not meet fire clearance.
  • At 3:05pm, LPA observed a walker, hoyer lift, 7 wheelchairs, a broken table, and 4 raised toilet seats in back yard, behind and on right side of house in back yard.
  • At 3:07pm, LPA observed exit gate locked with padlock on right side of house.
  • At 3:13pm, LPA observed insulin unlocked in refrigerator.
  • At 4:30pm, LPA observed facility was no conducting fire drills.


*An immediate civil penalty of $1000.00 will be assessed on today's date*
($500.00 for 87705(f) for padlock and $500.00 for 87202(a)(1) fire clearance for non-ambulatory).

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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: 06/05/2025
NARRATIVE
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Continued from LIC809C.

LPA requested the following documents to be submitted to CCLD by 6/12/2025.
  • Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • Liability insurance.
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan.

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, LIC421M, and this report provided
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 06:19 PM - It Cannot Be Edited


Created By: Laura Hall On 06/05/2025 at 05:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a fire clearance for five (5) non-ambulatory residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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2
3
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Administrator agreed to submit an updated facility sketch and an LIC200 to CCLD by POC date.
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above in having diabetic medication unlocked in refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Administrator agreed to lock up diabetic medication and submit a photo 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 06:19 PM - It Cannot Be Edited


Created By: Laura Hall On 06/05/2025 at 05:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having training for all staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2025
Plan of Correction
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Administrator agreed to get all staff trained and submit certifications and/or sign-in sheets to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in conducting a quarterly fire drill which poses a potential health, or safety risk to persons in care.
POC Due Date: 06/12/2025
Plan of Correction
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Administrator agreed to conduct a fire drill and submit documentation 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 06:19 PM - It Cannot Be Edited


Created By: Laura Hall On 06/05/2025 at 05:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above in having exit gate unlocked. LPA observed locked padlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Caregiver immediately removed padlock during visit. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 06:19 PM - It Cannot Be Edited


Created By: Laura Hall On 06/05/2025 at 05:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(B)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having all required furniture in residents bedrooms which poses personal rights risk to persons in care.
POC Due Date: 06/12/2025
Plan of Correction
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2
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4
Administrator agreed to purchase required furniture for residents bedrooms 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 06:19 PM - It Cannot Be Edited


Created By: Laura Hall On 06/05/2025 at 05:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGEL CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
(d) The following space and safety provisions shall apply to all facilities:

(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 cleared which poses a potential health or safety risk to persons in care.
POC Due Date: 06/12/2025
Plan of Correction
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2
3
4
Administrator agreed to have all items removed from passageways and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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