430707535-12-14-2023-26-AS-SRAI-CYJ64U-20231214192920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430707535
Report Date: 12/14/2023
Date Signed: 12/14/2023 07:29:25 PM

Document Has Been Signed on 12/14/2023 07:29 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	ANGEL HOME CARE		FACILITY NUMBER:	430707535
ADMINISTRATOR:	BERNARDO, ANGELITA		FACILITY TYPE:	735
ADDRESS:	3235 WELLCROFT COURT		TELEPHONE:	(408) 223-7244
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY: 6		CENSUS: 5	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Licensee/Administrator, Angelita Bernardo		TIME COMPLETED:	07:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Simi Rai and Mita Partoza conducted an unannounced Required 1 Year visit and met with Administrator, Angelita Bernardo. Upon entering the facility, LPAs observed volunteer (V1) at the facility with 4 residents inside the facility. LPAs spoke to the Licensee/Administrator over the phone to inform of the visit and Licensee/Administrator came to the facility afterwards. During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the one out of two exits were cleared of obstruction. The fence on the left side of the facility facing the street was obstructed by the blue recycling bin and the exit door was only able to open approximately 1 foot. LPAs observed 3 Lysol wipe cans near the door leading towards the backyard. LPAs observed unlocked chemicals in open cabinet on top of the laundry machine, which included but not limited to Clorox solution, laundry detergent and Windex cleaning solution. LPAs toured the facility living room and observed a knife on the table, accessible to the residents in the facility. LPAs observed the volunteer not in the room and not utilizing the knife at the time of inspection. LPAs observed a paper bag containing resident medication in the living room, which was not locked and accessible to the residents at the facility. LPAs observed a knife in the kitchen sink, where the kitchen was not being utilized for food prep at the time of inspection. LPAs toured the kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Continuation on LIC 809-C, Page 1 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGEL HOME CARE	FACILITY NUMBER: 430707535
	VISIT DATE: 12/14/2023

NARRATIVE

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Page 2 of 3.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 115.4F. The water temperature in the kitchen sink was 115.6F. Fire extinguisher was observed purchased new on January 19th 2023. Facility smoke detectors and carbon monoxide detectors were in working condition. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights.

LPAs observed the closet door in the hallway is not in good repair where the wheels on the door were not in the railing and the doors were not able to glide from left to right within the railing. LPAs observed the doors not properly in the appropriate railing and secured in place.

LPAs observed the last disaster drill to be conducted on January 27th 2023.

LPAs reviewed facility records for 3 residents. LPAs observed 3 out of the 4 resident files not containing signed Appraisal/Needs and Services Plan. LPAs observed 3 out of 4 resident files not containing medical consent forms not signed and available in the file. LPAs observed 2 out of 4 resident files not containing signed LIC 613 Personal Rights. LPAs observed 4 out of 4 resident files not containing weight records. Licensee stated she does not record the weight of the residents and did not know why she did not record the weight.

LPAs reviewed 1 staff file and 1 volunteer file.

LPAs reviewed resident medications and central stored medication records. LPAs observed the Centrally Stored Medication Records not completed for 4 out of 4 residents. Licensee stated she has not updated the Centrally Stored Medication Records for the residents yet.

This visit will be continued at a later date to deliver LIC 809-Ds observed during today's visit both Type A and Type B.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGEL HOME CARE	FACILITY NUMBER: 430707535
	VISIT DATE: 12/14/2023

NARRATIVE

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These deficiencies were discussed with Licensee/Administrator, Angelita Bernardo. The following deficiencies will be cited under the following regulations:

Type A: 80065(c)Personnel Requirements, 80075(k)(1) Health Related Services, 80087(g) Buildings and Grounds, 80087(a) Buildings and Grounds, 80087(c) Buildings and Grounds

Type B: 80075(k)(7) Health Related Services, 80068.2(a) Needs and Services Plan, 80075(h)(4)Health Related Services, 80072(a)(4) Personal Rights, 85075.4 Observation of the Client, 80023(d) Disaster and Mass Casualty Plan

All Type A deficiencies are due 24 hours before midnight on Friday, December 15th 2023.

All Type B deficiencies are due midnight on Thursday, December 21st 2023.

This report was reviewed with Licensee/Administrator, Angelita Bernardo. A copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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