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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 09/14/2023
Date Signed: 09/14/2023 01:53:48 PM


Document Has Been Signed on 09/14/2023 01:53 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: 2DATE:
09/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Wang Ding, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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On 9/14/2023 at 12:10pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Wang Ding, Administrator.

While LPA L. Hall was conducting a complaint investigation (15-AS-20230911111248) on 9/14/2023. During record review LPA observed both residents files were incomplete.

The following deficiencies were also observed:
  • At 12:20pm, LPA observed five (5) bottles of medicine in R1's bedroom sitting on night stand.
  • At 12:30am, LPA observed both client files were incomplete and S1 did not obtain any paperwork for the newly admitted client.


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, 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 $250.00 civil penalty will be assessed on today's date for a repeat violation*

Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/14/2023 01:53 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: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2023
Section Cited
CCR
87506(a)

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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:
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Administrator agreed to complete each resident file and submit a self-certification the files are complete by POC date.
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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.
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A $250.00 civil penalty will be assessed immediately.
Type A
09/15/2023
Section Cited
CCR87465(h)(2)

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87465 (h)... 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 responsible for the supervision... This requirement was not met as evidence by:
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Administrator immediately removed and locked medicines in closet. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited above in having medication inaccessible which poses an immediate 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: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2