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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294178
Report Date: 01/27/2024
Date Signed: 02/21/2024 12:54:43 PM


Document Has Been Signed on 02/21/2024 12:54 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/16/2024 05:44 PM

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

NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Xi-hua Luo . During visit, LPA observed 5 residents and 2 staff. (This report is being amended to add additional information.)

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 6 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. While touring the back yard, at 8:44am, LPA observed a shed, directly across from the sun room. ADM stated this is a staff room, where her staff member sleeps. ADM knocked on the shed, and a staff member with a pink robe exited. LPA interviewed staff S1. S1 stated he/she sleeps in the shed. Based on a review of the facility sketch, this shed is not part of the facility sketch. While inspecting the shed, LPA observed two cans of paint in the backside of the shed at 8:45am. While continuing the tour of the backyard, LPA observed another shed in the backyard, directly across the previous shed, at 8:45am. LPA observed staff S2 exit the shed, staff S2 stated that was his bedroom.

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 71 degrees F, and hot water temperature was
measured at 118 degrees F in resident bathrooms.

Fire extinguisher was serviced in July 17, 2023. 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 October 24, 2023.
Page 1 out of 2
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024
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 4


Document Has Been Signed on 02/21/2024 12:53 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/16/2024 05:44 PM

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: ANGELS SENIOR CARE HOME
FACILITY NUMBER: 435294178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA requested weight record for residents. ADM stated she used to do weigh the residents, but because they have trouble standing up, she doesn't have a weight record for those residents. The facility did not provide weight records for R1-R3. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated she will send plan of action on how the facility will maintain a weight records for her residents, to observe
changes in weight. ADM stated she will send plan of action to LPA by POC date, 2/03/2024.
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above. ADM, S1 and S2 confirmed that staff were sleeping in the storage units in the backyard. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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ADM stated he/she will send plan of action regarding staff sleeping in the backyard sheds. ADM stated he will send his/her written plan of action by POC date, February 28, 2024.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/27/2024 12:10 PM - It Cannot Be Edited

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: ANGELS SENIOR CARE HOME
FACILITY NUMBER: 435294178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 LPA's observation, LPA observed two cans of paint in the backside of the shed acessible to residents in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated she will send a plan of action on how she will ensure cleaning solutions and other items that could pose a danger is not acessible to residents in care. ADM stated she will send plan of action by poc date.
Type B
Section Cited
CCR
87207
87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. While reviewing R3's
medication records, one of R3's medications was two pills short, when cross referencing the medication start
date and the Medication administration record. ADM asked S3 what had occurred. S3 stated she did not know.this poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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Administrator will submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Administrator agreed and understood.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: ANGELS SENIOR CARE HOME
FACILITY NUMBER: 435294178
VISIT DATE: 01/27/2024
NARRATIVE
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LPA reviewed facility records for 3 staff and 3 residents. LPA requested weight record for residents. ADM
stated she used to do weigh the residents, but because they have trouble standing up, she doesn't have a
weight record for those residents. The facility did not provide weight records for R1-R3.

LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R3's
medication records, one of R3's medications was two pills short, when cross referencing the medication start
date and the Medication administration record. ADM asked S3 what had occurred. S3 stated she did not know. The medication start date was January 17,2024. The MAR showed 10 medications have been administered. And an audit of the medications showed 17 tablets where in the container. ADM could not explain where the two excess pills came from.

Licensee (LN) Yu Zhang stated that that backyard sheds have locks and have been locked. LN stated the residents don't have access to them. LN stated the backyard sheds are break rooms for staff to take a break as they need. LN stated no resident stays in the sheds.

LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

This report was reviewed with Administrator (ADM) Xi-hua Luo . A copy of the report was provided.
Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4