079200741-3-3-2023-15-AS-LHAL-CPL3YG-20230303173954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200741
Report Date: 03/03/2023
Date Signed: 03/03/2023 05:40:15 PM

Document Has Been Signed on 03/03/2023 05:40 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:	ANGEL'S LOVE RCFE		FACILITY NUMBER:	079200741
ADMINISTRATOR:	BADEO, MARCELINA M.		FACILITY TYPE:	740
ADDRESS:	281 PUEBLO DRIVE		TELEPHONE:	(925) 876-0605
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 5	DATE:	03/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Marcelina Badeo, Administrator		TIME COMPLETED:	05:50 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 3/3/2023 at 2:30PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Marcelina Badeo and explained the purpose of the visit. The Administrator currently holds a certificate (#6035565740) that expires on 06/23/2023. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of eight (8) total bedrooms which six (6) bedrooms are occupied by the residents and two (2) bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA observed pool in the back yard is inside a locked fence. A comfortable temperature is maintained at 70 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 at 110.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/20/2023. Emergency Disaster Plan was last posted on 10/08/2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/16/2022. Continued on LIC809.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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 6

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: ANGEL'S LOVE RCFE	FACILITY NUMBER: 079200741
	VISIT DATE: 03/03/2023

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
26
27
28
29
30
31
32

Continued from LIC809.

Three (3) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid certificate. All five (5) Clients records were reviewed.

LPA observed the following deficiencies:

At 2:37PM, LPA observed monitor sitting on kitchen counter watching R5 in bedroom.
At 2:48PM, LPA observed three (3) unlocked cabinets located in kitchen containing medication.
At 2:52PM, LPA observed locks on refrigerator and freezer in kitchen.
At 2:54PM, LPA observed 3 pair of scissors in unlocked kitchen drawer and 1 pair in dish dyer sitting on counter top.
At 2:55PM, LPA observed Clorox, Clorox disinfectant, Comet, knifes, and glade spray in unlocked cabinet underneath kitchen sink.
At 3:05PM, LA observer shared residents' bathroom did not have non-slip mat in shower.
At 4:15PM, LPA observed R1, R2, and R3 did not have doctor's orders for hospital bed with rails.

LPA requested the following documents to be submitted to CCLD by 3/10/2023.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: ANGEL'S LOVE RCFE	FACILITY NUMBER: 079200741
	VISIT DATE: 03/03/2023

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 26 27 28 29 30 31 32	Continued from LIC809C. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. A copy of appeal rights and this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 03/03/2023 05:40 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: ANGEL'S LOVE RCFE	FACILITY NUMBER: 079200741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having the Clorox, Comet, Clorox disinfectant, knives, scissors and other items inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2023
	Plan of Correction
1 2 3 4	Caregiver immediately locked cabinet that was located underneath the sink that contained items. Deficiency cleared during inspection. Deficiency cleared.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having medication inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2023
	Plan of Correction
1 2 3 4	Caregiver immediately locked cabinets that contained medication. Deficiency cleared during inspection.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 03/03/2023 05:40 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: ANGEL'S LOVE RCFE	FACILITY NUMBER: 079200741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a non-skid mat in shared residents' bathroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase and place a non-skid mat in the shared residents' bathroom and submit a photo to CCLD by POC date.

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having doctor's orders for hospital bed for R1, R2, and R3 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Administrator agreed to obtain a doctor's order for R1, R2, and R3 and submit a photo copy to CCLD by POC date.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 03/03/2023 05:40 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: ANGEL'S LOVE RCFE	FACILITY NUMBER: 079200741
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.2(a)(1)

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations,... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a monitor watching R5 in the bedroom and locking the refrigerator and freezer which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Administrator removed locks from refrigerator and freezer, and took out monitor from bedroom and kitchen counter. Deficiency cleared during inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6