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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200679
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:50:19 PM

Document Has Been Signed on 04/21/2022 04:50 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ANGIE'S HAVEN HOMEFACILITY NUMBER:
435200679
ADMINISTRATOR:PAUL ALIASONFACILITY TYPE:
735
ADDRESS:4881 LITTLE BRANHAM LANETELEPHONE:
(408) 978-5419
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 6DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Ely GalangTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Ely Galang. Upon arrival, HM took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, office, dinning room and two restrooms were inspected. Some trash cans were observed without covers. HM stated the facility will put the trash cans with covers in 3 days. No paper towel in kitchen and restrooms were observed. HM stated the facility will put the paper with holders in kitchen and restrooms in 3 days. 1 single resident bedroom, 3 shared resident bedrooms, 1 staff live-in room, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 72 degree F, and hot water temperature was at 109 degree F in facility.

Fire extinguisher was serviced in August 2021. The facility was equipped with fire alarm system. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated and done with boosters. No citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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