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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600911
Report Date: 01/15/2026
Date Signed: 01/16/2026 10:49:49 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/16/2026 10:49 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ANGEL HAVENFACILITY NUMBER:
415600911
ADMINISTRATOR/
DIRECTOR:		GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:1660 WOLFE DRIVETELEPHONE:
(650) 458-6166
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 5DATE:
01/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Golden Bell, Ferlene GiustoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 6 client bedrooms--all with exit doors--a staff room with 4 beds, 3 bathrooms, kitchen and living/dining room. There is a fenced and level backyard, and a detached storage shed. Washer and dryer are located in garage. No accessible bodies of water or fire safety hazards observed. PPE supply is inspected. Food supplies are maintained. A comfortable temperature is maintained, and hot water temperature tested at 116 degrees in rear bathroom. At least 2 of 3 toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 5 residents present and 3 staff. One resident is receiving hospice services. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including required staff records and training. Client and staff files are reviewed.
Ferlene Giusto is a RCFE administrator (x 7/27) that oversees facility operations.

The following information/forms are provided today:

- Personnel Report (LIC500)
- Proof of current liability insurance

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--2 pages.

****Due to printer malfunction, report could not be printed and will be emailed to Ms. Giusto***
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/16/2026 10:49 AM - It Cannot Be Edited


Created By: Audrey Jeung On 01/15/2026 at 12:57 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ANGEL HAVEN
FACILITY NUMBER: 415600911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2026
Section Cited
CCR
87608(a)(5)(B)

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POSTURAL SUPPORTS
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met, as there are
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Full bed rails will be included in hospice care plan for client #5, and copy will be sent to CCLD BY DUE DATE
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2 half bed rails on bed for client #5, but full bed rails are not included in hospice care plan. Licensee failed to ensure that hospice care plan includes full bed rails for client #5, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
01/22/2026
Section Cited
HSC1569.696

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All RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care...shall include 4 hours of training on the care, supervision, and special needs of those residents... 4 hours of training thereafter...per year....
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Proof that staff received at least 3 hours of training on postural supports and restricted health conditions will be sent to CCLD BY DUE DATE
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This requirement is not met, as there is no evidence that staff received training on postural supports and restricted health conditions, which poses a potential health, safety or personal rights risk.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/16/2026 10:49 AM - It Cannot Be Edited


Created By: Audrey Jeung On 01/15/2026 at 01:23 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ANGEL HAVEN
FACILITY NUMBER: 415600911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2026
Section Cited
HSC
1569.69

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HEALTH & SAFETY CODE
Each employee who received training and passed the exam required... and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues in each
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Staff will receive additional 2 hours of annual medications training, and proof of training will be sent to CCLD BY DUE DATE
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succeeding 12 month period. This requirement is not met, as there is no evidence that staff received 8 hours of medication training in 2025. Records show that staff received 6 hours of med training in 2025. Licensee failed to ensure that staff received required 8 hours of med training.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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