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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200531
Report Date: 08/12/2022
Date Signed: 08/12/2022 11:45:44 AM


Document Has Been Signed on 08/12/2022 11:45 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:ANGELS WINDSOR HOUSEFACILITY NUMBER:
019200531
ADMINISTRATOR:HAIDIE BAUTISTAFACILITY TYPE:
740
ADDRESS:2741 HILLEGASS AVENUETELEPHONE:
(510) 845-1850
CITY:BERKELEYSTATE: CAZIP CODE:
94705
CAPACITY:15CENSUS: 13DATE:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Haidie BautistaTIME COMPLETED:
12:00 PM
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On 08/12/2022 at 10:20 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct annual Infection Control Inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Administrator (ADM) Haidie Bautista was telephoned by the staff member and will be on her way; ADM arrived at 11:30 AM.

Facility has a COVID-19 mitigation plan on file. LPA obtained a staff and resident roster. LPA observed a screening station at the entry that contained thermometer, hand sanitizer, masks, gloves, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage, garage and backyard. LPA observed mask, cough etiquette, social distancing and some hand washing signs posted throughout. ADM to post 20 seconds handwashing signs to shared bathrooms. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. There is a surplus of PPE centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 105.3 degrees Fahrenheit (F) and the facility's temperature was 71 degrees (F). Fire extinguishers were observed full and last inspected on 10/11/2021. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Received staff roster)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview conducted and a copy of this report provided to ADM..
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022
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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