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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601400
Report Date: 02/03/2021
Date Signed: 02/03/2021 12:09:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ISLAND ANGEL CARE HOME FOR THE ELDERLYFACILITY NUMBER:
075601400
ADMINISTRATOR:RAMAIYA, MAVISFACILITY TYPE:
740
ADDRESS:5227 STEVEN S. STROUD DRIVETELEPHONE:
(925) 522-8084
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
02/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Gopal Ramaiya, AdministratorTIME COMPLETED:
11:49 AM
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On 02/03/21 at 11:15AM, LPA D Panlilio conducted a heath & safety tele-visit with administrator to follow-up on an incident report submitted to RO Oakland on 02/02/21 regarding resident (R1). LPA observed 2 staff wearing face masks during the tele-visit.

LPA observed 3 female residents (R2, R3 & R5) sitting 6 feet apart in the living room. They appeared relaxed and when asked if they are OK, they said "Yes". The other male residents were resting in their bedrooms during the tele-visit. They appeared OK. R1 was observed lying down in his bed relaxing. The other male resident (R4) was also observed resting in his bed. They appeared relaxed and comfortable in their surroundings. LPA observed staff attending to residents' needs during tele-visit. Staff appeared calm and attentive to residents' care.

LPA observed all residents are doing well and there were no immediate concerns regarding their health & safety.

No deficiencies were observed during this tele-visit. Due to COVID-19 shelter in place order, administrator was not physically available to sign this report.

Exit interview conducted and a copy of this report provided by email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2021
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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