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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601522
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:05:11 PM

Document Has Been Signed on 08/31/2023 12:05 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANGELS CARE HOMEFACILITY NUMBER:
075601522
ADMINISTRATOR:BANGI, ANGELINE SFACILITY TYPE:
740
ADDRESS:1511 BUENA VISTA STREETTELEPHONE:
(925) 219-2250
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Liezyl Ajos, AdministratorTIME COMPLETED:
12:15 PM
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On 08/31/2023 at 9:05 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Liezyl Ajos and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non Ambulatory.

LPA toured facility with Liezyl including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the residents and 2 bedrooms are occupied by staff. Staff occupy the bedrooms upstairs, upstairs is not accessible to residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 77 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 between 105 degrees Fahrenheit and 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/03/2023. First aid kit was observed to be complete.



Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGELS CARE HOME
FACILITY NUMBER: 075601522
VISIT DATE: 08/31/2023
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At 10:00 AM, LPA reviewed 6 of 6 residents records. At 9:30 AM, LPA reviewed 5 of 15 staff records and 5 of 5 have current first aid training and associated to the facility. At 11:15 AM, LPA reviewed a sample of 6 of 6 resident’s medications.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/21/2023:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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