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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200761
Report Date: 12/15/2023
Date Signed: 12/15/2023 11:29:08 AM


Document Has Been Signed on 12/15/2023 11:29 AM - 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:HOLY ANGEL HOME CARE 1FACILITY NUMBER:
079200761
ADMINISTRATOR:LIU, ALEXANDRIAFACILITY TYPE:
740
ADDRESS:1359 SUNFLOWER LANETELEPHONE:
(925) 626-3861
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 3DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Alexandria Liu, AdministratorTIME COMPLETED:
11:35 AM
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On 12/15/2023 at 9:35am, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson, conducted an unannounced 1-Year Required inspection. LPAs met with Alexandria Liu, Administrator and LPA explained the purpose of the visit. The facility’s fire clearance was approved for five (5) non-ambulatory and 1 bedridden resident.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 71 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 122.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 8/14/2023. Emergency Disaster Plan was last posted on 10/4/2022. First aid kit was observed to be complete.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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 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: HOLY ANGEL HOME CARE 1
FACILITY NUMBER: 079200761
VISIT DATE: 12/15/2023
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have criminal record clearance. All three (3) resident records were reviewed and complete.

LPA requested the following documents to be submitted to CCLD by 12/22/2023.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • Resident roster
  • Liability Insurance

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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