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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200679
Report Date: 03/29/2024
Date Signed: 03/29/2024 04:19:17 PM

Document Has Been Signed on 03/29/2024 04:19 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:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Paul AliasonTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Paul Aliason.

3 residents and 3 staff were observed in the facility.

LPA checked 3 resident record files (R1 - R3) and 3 staff record files (S1 - S3).

LPA toured the facility inside out with ADM. Living room, kitchen, office, dinning room and two restrooms were inspected. 2 single resident bedroom, 2 shared resident bedrooms, 1 staff live-in room, laundry room and garage were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and dish washing detergent closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 115 degree F in facility. First aid box and night lights were observed in the facility.

Fire extinguisher was serviced on 11/14/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways to the exit gate.

The last time the facility conducted the emergency and fire alarm drill was 8/2/2023.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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
Document Has Been Signed on 03/29/2024 04:19 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/29/2024 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGIE'S HAVEN HOME
FACILITY NUMBER: 435200679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that one of the resident bedroom was observed missing window screen which poses/posed a potential health to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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ADM stated to send a plan of correction by the POC due date to install a window screen for the resident bedroom.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that 1 out of 2 bathrooms was observed with non-skid mat which poses/posed a potential safety risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to install a non-skid mat in the bathroom.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/29/2024 04:19 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/29/2024 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGIE'S HAVEN HOME
FACILITY NUMBER: 435200679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that there was no flash light in the facility during the inspection which poses/posed a potential safety risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to have flash lights in the facility.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 1 out 3 resident admission agreement was observed without resident/family signature which poses/posed a potential health or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to have resident/family sign the admission agreement.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
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