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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200331
Report Date: 04/13/2022
Date Signed: 04/13/2022 04:34:41 PM


Document Has Been Signed on 04/13/2022 04:34 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:DREAN OF ANGEL CARE LLCFACILITY NUMBER:
079200331
ADMINISTRATOR:ANGIE ESPLANAFACILITY TYPE:
740
ADDRESS:274 STARLING WAYTELEPHONE:
(510) 313-0361
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Angelina Esplana, AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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On 04/13/2022 at 3:10pm, Licensing Program Analysts (LPAs) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs met with Angelina Esplana, Administrator and explained the purpose of the visit.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas.

During record review, LPA observed visitors log and temperature logs for residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 3:22pm LPA observed medication (eye drops) located in unlocked kitchen drawer.
-At 3:26pm LPA observed unlocked garage door with cleaning supplies such as pine sol, laundry soap, and knives gardening tools.
-At 3:28pm LPA observed a makeshift room located in the garage


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: DREAN OF ANGEL CARE LLC
FACILITY NUMBER: 079200331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care. Garage door was unlocked. Medication (eye drops) were located in a unlocked drawer in the kitchen.
POC Due Date: 04/14/2022
Plan of Correction
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Administrator will keep garage door locked at all times. Administrator locked medication (eye drops) with locked medication. corrections made during visit
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 1 of 1


Document Has Been Signed on 04/13/2022 04:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: DREAN OF ANGEL CARE LLC
FACILITY NUMBER: 079200331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(A)
87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement was not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care. Facility has a makeshift room in the garage.
POC Due Date: 04/20/2022
Plan of Correction
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Administrator agreed to dismantle the room in the garage and provide pictures to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3