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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801989
Report Date: 06/02/2021
Date Signed: 09/01/2021 08:18:52 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BENICIA ANGEL'S HOME 2 INC.FACILITY NUMBER:
486801989
ADMINISTRATOR:BAYON, EVELYNFACILITY TYPE:
740
ADDRESS:116 CARLISLE WAYTELEPHONE:
(707) 748-0482
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 4DATE:
06/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Administrator/Licensee, Evelyn BayonTIME COMPLETED:
12:14 PM
NARRATIVE
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Licensing Program Analyst (LPA) A. Canela arrived unannounced regarding another matter and met with care staff, Consuelo Nagal Cave. Upon entrance to the facility, staff S1 did not take LPAs temperature or requested LPA to sign in. LPA kept waiting at the front entrance and staff S1 returned to check LPA's temperature but no questions were asked regarding Covid-19 guidance and procedures. Staff was later identified as not being associated to this facility, Administrator stated S1 was not suppose to be at facility until she received the proper training. LPA observed S1 sitting in living room attending to a resident. LPA explained to Administrator no one should be in the facility without the proper fingerprint clearances or association.
LPA observed the gate at the bottom of the stairs was not secured to prevent residents from going upstairs. LPA also observed the medication closet was not locked. LPA requested facility staff to lock medication closet and explained it needs to be locked at all times. LPA observed 2 residents sitting and staff sitting with them. LPA consulted regarding gate at the bottom of the stairs to be secured to prevent access to residents in care.

LPA requested corrections to Mitigation Plan to be submitted by 6/15/2021 to LPA. A. Canela. LPA also requested current Physician Report for R1 and R2 to identify if they are bedridden.

Facility was also issued a Civil penalty in the amount of $100.00 for the following staff S1 who was not associated and did not have Fingerprint transfer by the Department.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, copy of this report and appeal of rights provided by email.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BENICIA ANGEL'S HOME 2 INC.
FACILITY NUMBER: 486801989
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2021
Section Cited

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87465(h)(2) Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible .
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to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met. As evidenced by: At around 11:20AM, LPA observed medication closet not locked. This is a Potential risk to residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BENICIA ANGEL'S HOME 2 INC.
FACILITY NUMBER: 486801989
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2021
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

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This requirement was not met. As evidenced by: during today's visit at 11:15 Staff (S1) was not associated to this facility. S1 has a fingerprint Exemption clearance and facility did not receive approval prior to staff working. This is an immediate risk to the Health and safety of residents in care.
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Statement facility understands S1 may not be present until associated properly. A civil penalty of $100.00 was issued for staff not being fingerprint Associated to facility.
POC due date 6/3/2021

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2021
LIC809 (FAS) - (06/04)
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