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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294178
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:42:04 AM


Document Has Been Signed on 01/27/2023 11:42 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:ANGELS SENIOR CARE HOMEFACILITY NUMBER:
435294178
ADMINISTRATOR:LUO, XI-HUAFACILITY TYPE:
740
ADDRESS:4078 FREED AVENUETELEPHONE:
(408) 244-7689
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 5DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Administrator, Julia (Xi-Hua) LuoTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Simi Rai and LPA Manuel Monter conducted an unannounced annual inspection focusing on infection control. LPAs met with Administrator, Julia (Xi-Hua) Luo. There are 5 clients at the facility and 2 staff including Administrator were observed.

During visit, LPAs toured the facility to include the 1 living room, 1 activity room, 5 resident rooms, 4 bathrooms, 1 staff room, kitchen, laundry area, dining area, garage and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked cabinet.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect twice daily and as often as needed. Bathrooms supplied with hygiene products and hand washing sign. Trash can with lid observed. LPAs observed a sufficient amount of Personal Protective Equipment (PPE). All staff are N95 fit tested. The following posters observed to include wash your hands, symptoms of COVID-19, importance of wearing a mask, cough etiquette and donning and doffing PPE.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Julia (Xi-Hua) Luo and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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