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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707535
Report Date: 12/16/2023
Date Signed: 12/16/2023 09:18:22 AM

Document Has Been Signed on 12/16/2023 09:18 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ANGEL HOME CAREFACILITY NUMBER:
430707535
ADMINISTRATOR:BERNARDO, ANGELITAFACILITY TYPE:
735
ADDRESS:3235 WELLCROFT COURTTELEPHONE:
(408) 223-7244
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
12/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Licensee/Administrator, Angelita BernardoTIME COMPLETED:
09:30 AM
NARRATIVE
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Licensing Program Analysts (LPA) Simi Rai and Mita Partoza conducted an unannounced case management visit. LPAs met with Licensee/Administrator, Angelita Bernardo.

LPAs delivered LIC 809-D from previous visit 12/14/2023.

Licensee verbally understood about the new Plan of Correction date.

All Type A deficiencies are due 24 hours before midnight on Sunday 12/17/2023. All Type B deficiencies are due midnight on Sunday 12/24/2023. LPAs reminded Licensee/Administrator to review all deficiencies and notify the Department for an extension and provide a valid reason and new date of extension.
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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: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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Document Has Been Signed on 12/16/2023 09:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/15/2023 at 07:55 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
, 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: 12/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2023
Section Cited
CCR
80065(c)

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80065 Personnel Requirements (c) The licensee shall be permitted to utilize volunteers provided that such volunteers are supervised, and are not included in the facility staff plan.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure volunteers will be supervised by staff by POC due date. Licensee/Administrator agreed and understood.
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Based on interview and observation, LPAs observed Volunteer (V1) without a staff supervising at the facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
12/17/2023
Section Cited
CCR80075(k)(1)

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80075 Health Related Services (k)(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and ensure medicatios are safe and locked by POC due date. Licensee/Administrator agreed and understood.
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Based on observation, LPAs observed a brown bag with R1's medication on a sofa, not locked and accessible at the facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


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Document Has Been Signed on 12/16/2023 09:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/15/2023 at 08:14 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
, 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: 12/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2023
Section Cited
CCR
80087(g)

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80087 Buildings 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:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure disinfectants, cleaning solutions and other items that could pose a danger are inaccessible to residents by POC due date. Licensee/Administrator agreed and understood.
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Based on observation, LPAs observed 2 knives, Lysol wipes, cleaning solution, and laundry detergent not locked and accessible to the residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
12/17/2023
Section Cited
CCR80087(a)

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80087 Buildings 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:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure closet door is in good repait at all times by POC due date. Licensee/Administrator agreed and understood.
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Based on observation, LPAs observe the closet door in the hallway is not in good repair which poses/posed an immediate Health, Safety, or Personal Rights risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


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Document Has Been Signed on 12/16/2023 09:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/15/2023 at 08:27 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
, 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: 12/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2023
Section Cited
CCR
80087(c)

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80087 Buildings and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure the exit door is free of obstruction at all times by POC due date. Licensee/Administrator agreed and understood.
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Based on observation, LPAs observed fence on the left side of the facility obstructed by the blue recycling bin and the exit door was only able to open approximately 1 foot which poses/posed an immediate Health, Safety, or Personal Rights risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


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Document Has Been Signed on 12/16/2023 09:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/15/2023 at 08:35 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
, 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: 12/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2023
Section Cited
CCR
80075(k)(7)

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80075 Health Related Services (k)(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure the maintenance of Centrally Stored Medication log for each resident by POC due date. Licensee/Administrator agreed and understood.
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Based on observation, record review and interview, 4 out of 4 residents Centrally Stored Medication log which was not complete which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/24/2023
Section Cited
CCR80068.2(a)

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80068.2 Needs and Services Plan (a) The licensee shall complete a Needs and Services Plan for each client as required in Sections 81068.2, 82068.2, 82568.2, or 85068.2.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure Needs and Services Plan are complete for each resident by POC due date. Licensee/Administrator agreed and understood.
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Based on record review and interview, 3 out of 4 resident Needs and Services Plan were incomplete which poses/posed a potential health, safety or personal rights risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


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Document Has Been Signed on 12/16/2023 09:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/15/2023 at 09:23 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
, 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: 12/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2023
Section Cited
CCR
80075(h)(4)

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80075 Health Related Services (h)(4) It is recommended that the licensee obtain consent forms to permit the authorization of medical care.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure consent forms are signed and in resident's file by POC due date. Licensee/Administrator agreed and understood.
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Based on record review, 3 out of 4 resident files did not contain consent forms to authorize medical care which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/24/2023
Section Cited
CCR80072(a)(4)

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80072 Personal Rights (a)(4) To be informed, and to have his/her authorized representative, if any, informed, by the licensee of the provisions of law regarding complaints...
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure residents and/or authorized representative signs Personal Rights and retained in resident's file by POC due date. Licensee/Administrator agreed and understood.
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Based on record review and interview, 2 out of 4 resident files did not have signed Personal Rights which poses/posed a potential health, safety or personal rights risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/16/2023 09:18 AM - It Cannot Be Edited


Created By: Simranjit Rai On 12/15/2023 at 09:30 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
, 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: 12/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2023
Section Cited
CCR
85075.4(c)

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85075.4 Observation of the Client (c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses ... to the attention of the client's physician and authorized representative, if any. This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will maintain weight log for each residents by POC due date. Licensee/Administrator agreed and understood.
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Based on record review, 4 out of 4 resident files did not contain weight record log which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/24/2023
Section Cited
CCR80023(d)

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80023 Disaster and Mass Casualty Plan (d) Disaster drills shall be conducted at least every six months.
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a plan of action understanding regulation and will ensure disaster drills are conducted at least every six months by POC due date. Licensee/Administrator agreed and understood.
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Based on record review and interview, the last diaster drill was conducted January 27, 2023 and diaster drill was not conducted at least every six months which poses/posed a potential health, safety or personal rights risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


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