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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441151
Report Date: 08/25/2021
Date Signed: 08/25/2021 01:26:11 PM

Document Has Been Signed on 08/25/2021 01:26 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:ANGELEON CARE HOMEFACILITY NUMBER:
011441151
ADMINISTRATOR:DE LEON, RICHARDFACILITY TYPE:
740
ADDRESS:2124 ASHBY AVENUETELEPHONE:
(510) 704-8319
CITY:BERKELEYSTATE: CAZIP CODE:
94705
CAPACITY: 12CENSUS: 11DATE:
08/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Danilo "sonny" Villar, CaregiverTIME COMPLETED:
01:30 PM
NARRATIVE
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On 8/25/2021 at 11:45AM Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct a Case Management. LPAs met with Danilo “Sonny” Villar.

When LPA L. Hall conducted the 10-day complaint visit (15-AS-20210518091350) on 6/10/2021, Staff (S2) stated that linens were changed once a week and comforters and blankets are washed bi-weekly or more if needed. While interviewing residents it was stated that linens and bedding was changed approximately 1 – 2 times per month.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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Document Has Been Signed on 08/25/2021 01:26 PM - It Cannot Be Edited


Created By: Laura Hall On 08/25/2021 at 12:45 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: ANGELEON CARE HOME
FACILITY NUMBER: 011441151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2021
Section Cited
CCR
87307(3)(C)

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87303 (3) Equipment and supplies... for personal care... shall be readily available... (C) Clean linen... shall be sufficient to permit changing at least once per week...to ensure that clean linen is in use... This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification stating that linens, comforters and blankets will be changed or washed once per week. Self-certification will be submitted to CCLD by POC date.
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Based on interviews Licensee did not comply with section cited above, which poses a potential 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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