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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601400
Report Date: 12/04/2024
Date Signed: 12/04/2024 02:59:05 PM

Document Has Been Signed on 12/04/2024 02:59 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ISLAND ANGEL CARE HOME FOR THE ELDERLYFACILITY NUMBER:
075601400
ADMINISTRATOR/
DIRECTOR:
RAMAIYA, MAVISFACILITY TYPE:
740
ADDRESS:5227 STEVEN S. STROUD DRIVETELEPHONE:
(925) 522-8084
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Mavis Ramaiya, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 12/04/24 at 2:30 PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed no clients living at the facility. ADM has a current administrator certificate # 7002527740 which expires 12/19/2025.

At 2:50PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 117 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 08/17/24. LPA reviewed one (1) staff file and observed it to be current.

Updated copies of the following documents were collected for facility file:
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.
Bennett FongTELEPHONE: (510) 622-2621
Daisy PanlilioTELEPHONE: (510) 286-4201
DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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