079200761-12-4-2024-15-AS-TSGN-DBN2W9-20241204164511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200761
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:45:21 PM

Document Has Been Signed on 12/04/2024 04:45 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:	HOLY ANGEL HOME CARE 1		FACILITY NUMBER:	079200761
ADMINISTRATOR/ DIRECTOR:	LIU, ALEXANDRIA		FACILITY TYPE:	740
ADDRESS:	1359 SUNFLOWER LANE		TELEPHONE:	(925) 626-3861
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	12/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:07 PM
MET WITH:	Merlita Vital, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 12/15/2023 at 1:07PM, Licensing Program Analyst (LPA) T. Syess-Gibson, conducted an unannounced 1-Year Required inspection. LPA met with Merlita Vital, Caregiver and LPA explained the purpose of the visit. Merlita contacted Administrator via telephone and explained purpose of visit. Administrator, Alexandria Liu arrived at 1:32PM. 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 73 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 111.8 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 08/14/2024. Emergency Disaster Plan was last posted on 12/13/2023. First aid kit was observed to be complete. Continued on LIC809C

Harpreet Humpal	TELEPHONE: (510) 285-3928
Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
	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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HOLY ANGEL HOME CARE 1	FACILITY NUMBER: 079200761
	VISIT DATE: 12/04/2024

NARRATIVE

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Continued from LIC809.

Three (3) staff records were reviewed and all staff have criminal record clearance. All four (4) resident records were reviewed and complete.

LPA requested the following documents to be submitted to CCLD by 12/11/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· Resident roster
· Liability Insurance

LPA observed the following deficiencies:

· At 2:00PM, LPA observed bleach disinfectant spray, fabuloso multi-purpose cleaner, laundry detergent and Windex in an unlocked garage.
· At 2:14PM, LPA observed scissors in an unlocked kitchen drawer.
· At 3:13PM, LPA observed during file review S1 and S2 weren't available at the facility for inspection.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties

Exit interview conducted and a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/04/2024 04:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HOLY ANGEL HOME CARE 1	FACILITY NUMBER: 079200761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having bleach disinfectant spray, fabuloso multi-purpose cleaner, laundry detergent and Windex window cleaner in an unlocked garage which poses an immediate health, safety risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Caregiver immediately removed items and placed items in a locked cabinet located in the garage. Deficiency cleared during visit.

Section Cited

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). 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 scissors in an unlocked kitchen drawer which poses an immediate health, safety risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Caregiver immediately removed scissors and placed them in a locked cabinet. Deficiency cleared during visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/04/2024 04:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HOLY ANGEL HOME CARE 1	FACILITY NUMBER: 079200761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 not having two (2) out of three (3) personnel records available to licensing to inspect during business hours which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have all personnel records available to licensing to inspect during normal business hours and will send a self-certifying email to CCLD by POC date.

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.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC809 (FAS) - (06/04)

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