<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294178
Report Date: 04/04/2024
Date Signed: 04/04/2024 12:15:34 PM


Document Has Been Signed on 04/04/2024 12:15 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
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: 6DATE:
04/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Xi-Hua LuoTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst’s Manuel Monter and Mita Partoza conducted an unannounced case management visit to follow up on deficiencies that were cited on a previous visit,dated January 27, 2024. LPAs met with Administrator Xi-Hua Luo and explained the purpose of the visit.

On April 4, 2024, Licensing Program Analysts asked ADM to show the backyard sheds. ADM stated she does not have the keys to the sheds and could not show LPA's the inside of the sheds. LPA spoke with ADM and ADM confirmed that she would send an updated plan of correction regarding staff sleeping in the backyard sheds.

During visit, LPA's observed the a section of fence in the backyard was in disrepair. ADM stated the fence in the backyard had multiple boards came loose due to the storm. ADM stated she is collaborating with her neighbor and will fix the fence as quickly as possible.

This report was reviewed with Administrator (ADM) Xi-hua Luo . A copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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 1