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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 12:51:31 PM


Document Has Been Signed on 02/21/2024 12:51 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/16/2024 05:35 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 duplicated report is being amended, due to being created erroneously.)

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.

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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)
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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: ANGELS SENIOR CARE HOME
FACILITY NUMBER: 435294178
VISIT DATE: 01/27/2024
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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. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Xi-hua Luo and a copy of the signed report & appeal rights were provided.

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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: 2 of 4
Document Has Been Signed on 01/27/2024 11:26 AM - 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
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 record review and interview, the licensee did not comply with the section cited above. 3 out of 3 resident files reviewed do not have a weight record. ADM stated because residents have trouble standing up, she doesn't have a weight record for those residents. 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 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 interview, the licensee did not comply with the section cited above. LPA observed two sheds in the backyard. S1 confirmed he/she sleeps in the shed across from the sun room. S2 stated the other shed is his/her bedroom. ADM confirmed S1 sleeps in the shed. 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 will send photo documentation showing the storage area is no longer being used as a sleeping area. ADM stated she will also send a letter of understanding stating no staff or any individual is allowed to sleep in the following areas without building permit and fire clearance such as but not limited to; the sheds, living room, and garage.
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


Document Has Been Signed on 02/21/2024 12:52 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/16/2024 05:36 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
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 accessible 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 accessible to residents in care. ADM stated she will send plan of action by poc date. (This a report is a duplicate that was created erroneously. )
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 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)
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