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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600911
Report Date: 01/16/2025
Date Signed: 01/16/2025 07:04:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/16/2025 07:04 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
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: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Golden Bell, Francheska Mendoza, April SantosTIME VISIT/
INSPECTION COMPLETED:
07:00 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 110 degrees in bathroom near staff room. 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 6 residents present and 3 staff. Three residents receive 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. Six client files are reviewed, including Centrally Stored Medications REcord for one client. Francheska Mendoza is a RCFE administrator (x 11/25) that oversees facility operations.

The following information/forms are provided today:

- Personnel Report (LIC500)
- Proof of current liability insurance
- Designation of Administrative Responsibility (LIC308)



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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 01/16/2025 07:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/16/2025 at 05:38 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: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2025
Section Cited
CCR
87309(a)

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STORAGE SPACE
The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage.
This requirement was not met, as Comet
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Bathroom cabinets were locked in LPA's presence.
Deficiency corrected and cleared
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cleansers are stored in cabinets in 2 bathrooms used by clients. Licensee failed to ensure that cleaning products are stored in secure area, inaccessible to clients. This poses an immediate health, safety or personal rights risk to clients in care.
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Type A
01/17/2025
Section Cited
CCR87608(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 client #4 has full bed rails, but there is no
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Plan/proof of correction to be sent to CCLD BY DUE DATE.
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hospice care plan on file. Licensee failed to ensure that hospice client has hospice care plan that includes full bed rails, which poses an immedicate health, safety or personal rights risk to clients 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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


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Document Has Been Signed on 01/16/2025 07:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/16/2025 at 05:49 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: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2025
Section Cited
CCR
87309(a)(3)(B)

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PERSONAL ACCOMMODATION SVCS
The licensee shall ensure provision of bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement was not met, as there are no night stands or reading lamps in
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Nightstands and reading lights will be installed in all clients' rooms.
Proof of correction to be sent to CCLD BY DUE DATE
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at least 4 out of 6 rooms, which poses a potential health, safety, or personal rights risk to clients in care. Licensee failed to ensure that all residents are provided with required furnishings.
No nightstands and reading lights in rooms of C1, C2, C3, C6
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Type B
01/30/2025
Section Cited
CCR87465(h)(4)

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INCIDENTAL MEDICAL CARE
No persons other than the dispensing pharmacist shall alter a prescription label.
This requirement was not met, as start dates are written on Rx labels by staff. Licensee failed to ensure that no one alters Rx labels, which poses a potential health, safety, or personal rights risk.
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Staff will immediately stop writing on Rx labels.

Proof/plan of ocrrection to be sent to CCLD BY DUE DATE.

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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/16/2025 07:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/16/2025 at 06:01 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: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2025
Section Cited
CCR
87458((c)(1)(A)

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MEDICAL ASSESSMENTS
The medical assessment shall include...a physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for... communicable tuberculosis.
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TB test results for C1, C2, C6 will be sent to CCLD BY DUE DATE
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This requirement is not met, as TB test results are not maintained for 3 out of 6 residents. Licensee failed to ensure that all clients have TB test results on file, which poses a potential health, safety or personal rights risk to clients in care. Clients #1, #2, #6 do not have TB test results on file.
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Type B
01/30/2025
Section Cited
CCR87507(g)(3)(A)

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ADMISSION AGREEMENTS
Admission agreements shall specify... payment provisions, including...rate for all basic services which the facility is required to provide.
This requirement is not met, as admission agreements for 2 out of 6 clients do not include monthly rate.
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Monthly rates will be added to admission agreements for clients #3 and #6.
Copies of admission agreements with monthly rates initialled by responsible parties will be sent to CCLD BY DUE DATE.
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Licensee failed to ensure that basic rate is included in signed admission agreements, which poses a potential health, safety or personal rights risk to clients. Monthly rate missing for clients #3 and #6.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


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Document Has Been Signed on 01/16/2025 07:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/16/2025 at 06:16 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: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2025
Section Cited
CCR
87633(b)(1-7)

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HOSPICE CARE
A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include specific information.
This requirement was not met, as there are no hospice care plans maintained for 2 out
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HOspice care plans for clients #4 and #6 will be sent to CCLD BY DUE DATE.
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of 3 hospice residents. Licensee failed to ensure that hospice care plans are maintained for all those receiving hospice care. This poses a potential health, safety or personal rights risk to clients in care.
No hospice care plans for clients #4 and #6.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


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