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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801989
Report Date: 11/22/2021
Date Signed: 11/23/2021 11:38:03 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: 0DATE:
11/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Evelyn BayonTIME COMPLETED:
10:50 AM
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 (LPA) A. Canela arrived unannounced at Benicia Angel's Home 2 Inc on 11/22/2021 for the purpose of conducting a Case Management visit and issue citations for previous items that were observed and/or documented. LPA called licensee by phone and Evelyn Bayon (EB) arrived a few minutes later. There are no residents living in the home and home has been sold.

LPA disclosed to licensee that facility staff failed to wear face covering while providing care and supervision to residents in this facility. Staff were observed sitting next to residents and not wearing masks as mandated during the pandemic. Administrator failed to ensure staff followed COvid-19 precautions, CCL and CDC recommendations. Administrator/licensee should oversee facility and ensure facility is following requirements for providing care and supervision appropriate to the residents.

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: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 2
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: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2021
Section Cited

1
2
3
4
5
6
7
87468.1(a)(2)Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations,
8
9
10
11
12
13
14
 furnishings and equipment. This requirement was not met. As evidenced by: Staff were observed not wearing face covering and caring for residents- during Covid-19 mandate, that all staff shall wear face coveings for the protection or transmittal of Covid-19. This is an immediate risk to the health & safety of residents in care.
8
9
10
11
12
13
14
POC due date 11/23/2021 to LPA Araceli Canela
Type B
11/26/2021
Section Cited

1
2
3
4
5
6
7
87405(d)(1) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
8
9
10
11
12
13
14
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirment was not met. As evidenced By: Administrator failed to ensure & had knowledge staff did not always wear face coverings,while providing care to residents - This is a potential risk to residents in care.
8
9
10
11
12
13
14
POC due date 11/26/2021 to LPA A. Canela
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: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2