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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601522
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:17:51 PM


Document Has Been Signed on 01/26/2024 02:17 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ANGELS CARE HOMEFACILITY NUMBER:
075601522
ADMINISTRATOR:BANGI, ANGELINE SFACILITY TYPE:
740
ADDRESS:1511 BUENA VISTA STREETTELEPHONE:
(925) 219-2250
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 AM
MET WITH:Administrator, Liezyl AjosTIME COMPLETED:
02:30 PM
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
On 01/26/2024 at 12:25 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Liezyl Ajos and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non Ambulatory.

LPA toured facility with Liezyl including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the residents and 2 bedrooms are occupied by staff. Staff occupy the bedrooms upstairs, upstairs is not accessible to residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured 119.3 degrees Fahrenheit and 120 degrees Fahrenheit in master bathroom. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/11/2023. First aid kit was observed to be complete.

LPA reviewed 5 residents records. LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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 1