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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294306
Report Date: 09/24/2021
Date Signed: 09/29/2021 10:02:02 AM

Document Has Been Signed on 09/29/2021 10:02 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:QUEEN OF ANGELS II RCFEFACILITY NUMBER:
275294306
ADMINISTRATOR:ANDOY, MERZAFACILITY TYPE:
740
ADDRESS:745 CARMELITA DRIVETELEPHONE:
(831) 758-8121
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 6CENSUS: 5DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Merza AndoyTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Licensee Merza Andoy.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, thermometer, hand sanitizer, and sign in sheet were present at the entrance. LPA was temperature checked and screened before entering.

LPA toured the facility. The facility was observed to be in sanitary condition and in comfortable temperature. All staff members were wearing masks. There were COVID-19 signs and hand sanitizers at the entrance and throughout the facility.

LPA inspected 1 restroom. The restroom was observed to be adequately stocked with paper towels, hand soap, and covered trash bin. Hand washing signs were present. Hand washing sign was also posted in the kitchen to remind the kitchen staff to wash their hands before handling food. LPA checked the supply of the personal protective equipment in the storage area.

LPA discussed the infection control and reviewed the current Provider Information Notice PIN 21-40-ASC with Licensee. All residents and all staff were fully vaccinated and required so according to facility's policy.

Advisory notes were issued. No deficiency cited during visit.

This report was reviewed with Licensee. A copy of this report and advisory notes were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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