Community Care Licensing

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Laura Hall TELEPHONE: (510) 622-2024 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023

Document Has Been Signed on 08/22/2023 01:48 PM - It Cannot Be Edited

FACILITY NAME: ANGEL CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/29/2023 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator agreed to complete each resident file and submit a self-certification the files are complete by POC date.
	8 9 10 11 12 13 14	Based on record review and interview the licensee did not comply with the section cited above in having complete records for residents, which poses a potential health and safety risk for persons in care.	8 9 10 11 12 13 14
Type B 08/29/2023 Section Cited CCR87412(a)	1 2 3 4 5 6 7	87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator agreed to complete S2 personnel file, and submit self-certification that the files are complete by POC date.
	8 9 10 11 12 13 14	Based on record review and interview the Licensee did not comply with the section cited above in having a complete file for S2 which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	*Immediate $250 civil penalty for repeat*

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Laura Hall TELEPHONE: (510) 622-2024 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023

Document Has Been Signed on 08/22/2023 01:48 PM - It Cannot Be Edited

FACILITY NAME: ANGEL CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/23/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 (h) The following requirements shall apply to medications which are centrally stored: (2) ... medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator locked medicine closet immediately upon arrival. Deficiency cleared during visit.
	8 9 10 11 12 13 14	Based on observation the Licensee did not comply with the section cited above in having medicine inaccessible to residents, which posed an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Laura Hall TELEPHONE: (510) 622-2024 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023

Document Has Been Signed on 08/22/2023 01:48 PM - It Cannot Be Edited

FACILITY NAME: ANGEL CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/29/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.	1 2 3 4 5 6 7	Administrator agreed to review regulation 87211 and submit self-certification that the regulation has been reviewed and will be abided by going forward to CCLD by POC date.
	8 9 10 11 12 13 14	Based on interview and record review, the Licensee did not comply with the section cited above in submitting and death report and incident report for residents, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 08/29/2023 Section Cited CCR87305(a)	1 2 3 4 5 6 7	87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator agreed to submit and updated LIC200 and facility sketch to CCLD by POC date.
	8 9 10 11 12 13 14	Based on observation and record review the Licensee did not comply with the section cited above in obtaining a permit which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Laura Hall TELEPHONE: (510) 622-2024 LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023