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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:56:34 PM


Document Has Been Signed on 09/29/2023 03:56 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:
09/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Mary Lorraine Adriatico, CaregiverTIME COMPLETED:
04:00 PM
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On 9/29/2023 at 3:30pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Mary Lorraine Adriatico, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Ding Wang, via telephone

LPA conducted a case management visit on 9/14/2023 and cited facility for the following:

  • 87506(a) Resident records - LPA observed during today's visit both client records are complete.

No deficiencies cited during visit.

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: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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