079201134-5-18-2023-15-AS-LHAL-CRY5DE-20230518195148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 05/18/2023
Date Signed: 05/18/2023 07:52:07 PM

Document Has Been Signed on 05/18/2023 07:52 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 CARE HOME		FACILITY NUMBER:	079201134
ADMINISTRATOR:	WANG, DING		FACILITY TYPE:	740
ADDRESS:	1723 LIMEWOOD PLACE		TELEPHONE:	(925) 890-8953
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94553
CAPACITY:	6	CENSUS: 3	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Mary Lorraine Adriatico, Direct Support Professional		TIME COMPLETED:	08:10 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 5/18/2023 at 1:45PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Mary Lorraine Adriatico, Direct Support Professional (DSP) and explained the purpose of the visit. Ding Wang, Administrator arrived at 2:50PM. The Administrator currently holds a certificate (#6055098740) that expires on 01/29/2024. The facility’s fire clearance was approved for four (4) ambulatory, one (1) non-ambulatory, and one (1) bedridden resident. LPA toured the facility with DSP including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms which one (1) bedroom is occupied by staff, and two one-half (2-1/2) bathrooms. LPA observed pool in the backyard has locked gate. A comfortable temperature is maintained at 79 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 129.6 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: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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 10

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 CARE HOME	FACILITY NUMBER: 079201134
	VISIT DATE: 05/18/2023

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.

Facility did not have Administrator file available and staff file was not complete. All three (3) residents' file were reviewed and all were incomplete.

LPA observed the following deficiencies:

At 1:50PM, LPA observed an inoperable microwave sitting outside in the driveway.
At 2:00PM, LPA observed 2 bottle of melatonin, a bottle of joint pills in unlocked kitchen drawer.
At 2:03PM, LPA observed oven cleaner, Odoban disinfectant and Pine-Sol in unlocked cabinet underneath kitchen sink and a pair of scissors in utensil holder on kitchen counter.
At 2:05PM, LPA observed a room built for staff in garage.
At 2:07PM, LPA observed medication closet with medication in it unlocked.
At 2:10PM, LPA observed Ajax and a bottle of disinfectant in 1/2 bathroom in unlocked cabinet underneath the sink.
At 2:15PM, LPA observed two (2) shower glass doors, a wooden bed frame, a shovel, and a rake in passageway on left-side of house.
At 2:18PM, LPA observed drawers, a ladder, and a bed frame in passageway on right-side of house.
At 2:40PM, LPA observed during record review that R3 had been hospitalized several times (6). Administrator did not report hospitalization to CCLD.
At 3:35PM, LPA observed during record review that the facility does not have a personnel file for S1 or a complete file for S2 (1st Aid, CPR, health screening, TB, employee rights, training records)
At 3:40PM, LPA observed during record review resident records were incomplete.

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: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

Page: 2 of 10

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 CARE HOME	FACILITY NUMBER: 079201134
	VISIT DATE: 05/18/2023

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.

LPA requested the following documents to be submitted to CCLD by 5/25/2023.

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

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: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

Page: 3 of 10

Document Has Been Signed on 05/18/2023 07:52 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 CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in not obtaining a fire clearance or contacting CCLD regarding alterations which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit and updated LIC200 and facility sketch to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 passageways free of obstruction which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove all items out of passageways and submit photo 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: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

Page: 4 of 10

Document Has Been Signed on 05/18/2023 07:52 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 CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(a)

Other Provisions

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in being present during normal working hours which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to review the section cited above and regulation 87404, and submit a self-certification that the section and regulation has been reviewed and Administrator will abide by the regulation going forward by the POC date.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having the Administrator file at the facility and the staff file complete which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to complete personnel files, and submit self-certification that the files are complete 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: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 05/18/2023 07:52 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 CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having resident files complete which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to complete each resident file and submit a self-certification the files are complete by POC date.

Type B

Section Cited

CCR

87211(a)(D)

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in reporting incidents of residents to CCLD which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Administrator agreed to review regulation 87211 and submit self-certification that the regulation has been reviewed and will be abided by going forward 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: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

Page: 6 of 10

Document Has Been Signed on 05/18/2023 07:52 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 CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

(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 disinfectants and cleaning supplies accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Administrator agreed to lock cleaning supplies and disinfectants away and take photo of locked cabinet and submit photo 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

Page: 10 of 10