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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601522
Report Date: 01/18/2022
Date Signed: 01/18/2022 12:19:14 PM

Document Has Been Signed on 01/18/2022 12:19 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANGELS CARE HOMEFACILITY NUMBER:
075601522
ADMINISTRATOR:NIDUAZA, MARIA DULCEFACILITY TYPE:
740
ADDRESS:1511 BUENA VISTA STREETTELEPHONE:
(925) 219-2250
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
01/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maria Dulce NiduazaTIME COMPLETED:
12:35 PM
NARRATIVE
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On 1/18/2022 at 10:15AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with S2, LPA called licensee Maria Niduaza . Licensee Maria arrived at the facility around 10:30AM. LPA observed 4 residents during the visit. Facility has approved 6 hospice residents and currently have 3 hospice residents. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing.

LPA inspected the physical plant, but not limited to the kitchen, dining area, resident's bedrooms, bathroom, laundry room, and backyard. LPA observed there is enough furniture and lighting throughout the facility. LPA observed there is a seven day non-perishable and two-way perishable food supply, and cleaning supplies and toxins were locked. The smoke detectors and carbon monoxide detectors are in compliance with fire safety. Infection control designated leader Maria Niduaza & Liezyl Ajos.



Continued on next page LIC 809-C


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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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Document Has Been Signed on 01/18/2022 12:19 PM - It Cannot Be Edited


Created By: Leslie Ibo On 01/18/2022 at 11:36 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGELS CARE HOME
FACILITY NUMBER: 075601522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)(3)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute maybe a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:
(3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above there is no current certified Administrator working at the facility, current administrator has expired certificate on 12/15/2019 and back up administrator S2 has also expired administrator certificate on 12/1/2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2022
Plan of Correction
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Licensee Maria Niduaza needs to identify a certified Administrator to oversee the proper business business operation, licensee needs to submit proof of employment at CCL office 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
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2022


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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGELS CARE HOME
FACILITY NUMBER: 075601522
VISIT DATE: 01/18/2022
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LPA observed the following:

· Licensee has not provided all staff with fit testing for N95 respirators.
· Current Administrator and back up Administrator (S4) has expired administrator certificate.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Maria Niduaza.

Exit interview and appeal rights conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
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