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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707535
Report Date: 02/19/2025
Date Signed: 02/19/2025 12:26:16 PM

Document Has Been Signed on 02/19/2025 12:26 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 CAREFACILITY NUMBER:
430707535
ADMINISTRATOR/
DIRECTOR:		BERNARDO, ANGELITAFACILITY TYPE:
735
ADDRESS:3235 WELLCROFT COURTTELEPHONE:
(408) 223-7244
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Angelita BernardoTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Angelita Bernardo. During the visit, LPA observed 2 residents and 1 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. LPA observed a storage space area in the backyard being used for storage. There was no obstruction to block the walkways. During the tour of the facility, LPA noted to ADM the clutter throughout the facility. LPA advised to ADM to de-clutter her facility. While touring the backyard, LPA observed a can of butane gas cartridge, directly in front of the storage area, accessible to residents in care. (Photograph was taken.) ADM put locked the can during visit.

During the tour of the facility, LPA observed the facility garage had a partition wall, with 2 bedrooms inside. ADM showed LPA, City of San Jose Department of building plot plan. LPA informed ADM, the Department would follow up on this change, as it is not reflected on the facility sketch.

While touring the resident bedrooms, LPA observed dirt and grime on the walls, window shades, light shade. LPA also observed cobwebs in each of the residents bedrooms, including the hallway bathroom. (Photographs were taken.) While touring the resident bedroom farthest from the front door, had a dresser that was missing one of its shelves. (Photograph was taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 108 degrees F in both bathrooms. Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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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: 02/19/2025
NARRATIVE
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Fire extinguisher was serviced in December 2, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 27, 2023. ADM stated she conducted drills in 2024, but doesn't know where the documentation is.

LPA reviewed facility records for 3 residents. LPA requested to see R1 & R3's personal property/valuables log. ADM stated she did not do it for R1 and R3. LPA reviewed 3 staff records. LPA requested to see documentation showing that the ADM, S1 and S2 have completed their first aid. ADM stated they have completed the first aid training, but don't have documentation to show to LPA during visit. LPA also reviewed 3 resident medications and centrally stored medication records.

LPA requested a copy of the following forms be sent to the Department by February 28, 2025.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. LIC309, Administrative Organization
8. Emergency Disaster Plan LIC 610D (10/03) (PUBLIC)

Deficiencies cited during today's visit. This report was reviewed with Administrator Angelita Bernardo and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/19/2025 12:26 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/19/2025 at 11:55 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGEL HOME CARE
FACILITY NUMBER: 430707535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. While touring the backyard, LPA observed a can of butane gas cartridge, directly in front of the storage area, accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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ADM secured the butane gas cartridge during visit. ADM stated she will send a letter of understanding regarding the regulation, and the importance of ensuring Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger to residents are inaccessible to residents in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/19/2025 12:26 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/19/2025 at 11:55 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGEL HOME CARE
FACILITY NUMBER: 430707535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed resident bedrooms, had dirt and grime on the walls, window shades, light shade and cobwebs in each of the residents bedrooms, including the hallway bathroom. LPA observed the resident bedroom farthest from the front door, had a dresser that was missing one of its shelves. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the facility is clean, safe, sanitary & in good repair at all times for the safety & well-being of clients, employees and visitors. ADM stated she will address the dirt/grime in the residents blinds, bedrooms & the cobwebs throughout the facility. ADM stated she would also address the missing shelve in the residents dresser. ADM stated she will send photo documentation & the written plan by POC date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above. LPA requested LPA requested to see documentation showing that the ADM, S1 and S2 have completed their first aid. ADM stated they have completed the first aid training, but don't have documentation to show to LPA during visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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ADM stated she will ensure all her staff have completed their first aid training. ADM stated she will send LPA documentation showing they have completed their first aid training. ADM stated she will send to LPA by POC date, February 26, 2025.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/19/2025 12:26 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/19/2025 at 11:55 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGEL HOME CARE
FACILITY NUMBER: 430707535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA requested to see R1 & R3's personal property/valuables log. ADM stated she did not do it for R1 and R3. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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ADM stated she will fill out the personal property forms for all her residents and send LPA documentation showing it has been completed. ADM stated she will send to LPA by POC date, February 26, 2025
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA observed facility fire/earthquake drill log. The facility's last drill was on January 27, 2023. ADM stated she did conduct drills in 2024, but doesn't know where it is. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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ADM stated she will conduct a drill this week and send LPA documentation showing a drill has taken place. ADM stated she will also send a letter of understanding regarding the regulation, and ensuring that she will conduct a drill at least quarterly for each shift, including Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. ADM stated she will send to LPA by POC date.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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