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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 05/23/2022
Date Signed: 05/23/2022 09:57:36 AM


Document Has Been Signed on 05/23/2022 09:57 AM - 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) 890-8953
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 0DATE:
05/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
10:05 AM
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On 5/23/2022 at 9:10AM Licensing Program Analyst (LPA) L. Hall conducted an continued announced pre-licensing inspection and met with Ding Wang, Licensee/Administrator.

LPA toured the bedrooms, bathrooms, common living areas, kitchen, and backyard. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture and lighting. Residents rooms have proper bedding and linens for the use. Bathrooms were equipped with grab bars. Living room is equipped with the proper furniture for the residents. Hallways and passageways are free of obstruction. Facility has a swimming pool in back yard has been enclosed. LPA observed locked closet for medication and locks placed on cabinets in kitchen for sharps and toxins. First aid kit is complete.

LPA presented Component III power point during visit and discussed the regulations embodied in the power point. LPA observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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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