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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200679
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:59:08 PM

Document Has Been Signed on 05/13/2022 04:59 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ANGIE'S HAVEN HOMEFACILITY NUMBER:
435200679
ADMINISTRATOR:PAUL ALIASONFACILITY TYPE:
735
ADDRESS:4881 LITTLE BRANHAM LANETELEPHONE:
(408) 978-5419
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 6DATE:
05/13/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:PAUL ALIASONTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Steve Chang, and Program Clinical Consultant (PCC) Helen Shi conducted Technical Assistant - PCC through tele-inspection (Zoom), and met with Administrator (ADM) Paul Aliason.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance. Screening station with screening questionnaire, hand sanitizer, face masks, thermometer, glove, and a visitor log was observed at the main entrance.

The facility common areas were inspected such as the kitchen, living room, dinning area, bathrooms. There are 3 resident shared bedrooms, 1 single resident bedroom, 1 staff live-in bedroom, and 2 bathrooms in facility. Trash cans were observed with covers. Paper towels with holders were observed. The laundry room was observed and inspected. One restroom was dedicated for positive residents and staff. One restroom was dedicated for negative residents and staff. Two resident bedrooms were dedicated for 4 positive residents. ADM stated currently the facility does not allow visitor to enter the facility.

ADM stated all the residents and staff are fully vaccinated and finished with booster shots.

Based on today's inspection, below are the recommendations:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ANGIE'S HAVEN HOME
FACILITY NUMBER: 435200679
VISIT DATE: 05/13/2022
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1. Facility to use disposable dishes and utensils for positive residents.
2. Administrator to review PINs on isolation.
3. Facility to have N95 fitting test for staff who are caring for positive residents.
4. Facility to do the laundry for negative residents first.
5. Facility to conduct staff training at least quarterly or as frequently as needed on
donning and doffing of PPE, COVID -19 updates by CDC, and/or local public
health and to review DSS-CCLD Providers Information Notice (PIN).
6. Facility to disinfect the high touched areas based on manufacture’s instruction on disinfection.
7. Facility to separate each resident's laundry load.
8. Facility to use the highest temperature for positive residents’ laundry.
9. Staff should be wearing N95 during this outbreak.
10. PIN information: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/adult-senior-care
1. LPA provide some resource in other email to ADM.

No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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