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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294178
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:32:29 PM

Document Has Been Signed on 01/09/2025 02:32 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/
DIRECTOR:		LUO, XI-HUAFACILITY TYPE:
740
ADDRESS:4078 FREED AVENUETELEPHONE:
(408) 244-7689
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Licensee Yu ZhangTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Santino Fortes & Christine Dolores conducted an unannounced annual inspection, and met with Caregiver Licensee Yu Zhang. Licensee informed that facility has 3 staff and 6 clients.

LPAs toured the facility inside out including: kitchen, living room, family room and 1 staff room, 6 resident rooms and 4 restrooms. Restrooms observed to have non-skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least seven days. Refrigerator temperature was observed at 42 degrees F and Freezer temperature was 0 Degrees F. The front yard and backyard of the facility was also inspected. There was no obstruction to block the outdoor exits. Two storage sheds were observed. Storage shed on east side of of backyard was observed to be used for storage. The west side storage shed was observed to be used as a living space by staff.

LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 74 degree F, and hot water temperature was initially measured at 149.0 in the hallway bathroom and 151.1 degrees F from a resident bathroom. Licensee adjusted the water temperature during visit. The hot water temperature measured from resident bathroom at 105 degrees F and 106 degrees F in the kitchen. LPA inspected the facility first aid kit and it was observed to be complete. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. Fire extinguishers were last serviced on 7/11/24. The facility last fire drill was conducted on 3/27/24.

LPA reviewed facility records for 5 staff and 6 clients. LPA reviewed 6 clients medications and centrally stored medication records and observed to be accurate .

Deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with Licensee. This report was reviewed and a copy was provided to Licensee for signature.

Jackie JinTELEPHONE: (714) 319-3786
Santino FortesTELEPHONE: (818) 378-8120
DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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Document Has Been Signed on 01/09/2025 02:32 PM - It Cannot Be Edited


Created By: Santino Fortes On 01/09/2025 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)
Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by allowing staff to use shed as a living space which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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LIcensee will return shed to purpose of storing material items rather than a living space for staff and provide pictures of correction.
Type A
Section Cited
CCR
87303(e)(2)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which water temperature was observed at 149.0 degrees F which is not within limits and poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Licensee adjusted water temperature during inspection and adjusted temperature was observed at 105.0 Degrees F. Licensee will maintain a water tempurature log to document and ensure water temperatures remain within safe levels.
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:Jackie Jin
TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME:Santino Fortes
TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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