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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601522
Report Date: 01/02/2025
Date Signed: 01/02/2025 02:09:16 PM

Document Has Been Signed on 01/02/2025 02:09 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ANGELS CARE HOMEFACILITY NUMBER:
075601522
ADMINISTRATOR/
DIRECTOR:		BANGI, ANGELINE SFACILITY TYPE:
740
ADDRESS:1511 BUENA VISTA STREETTELEPHONE:
(925) 219-2250
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
01/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Liezyl Ajos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 01/26/2024 at 10:15AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Liezyl Ajos and explained the purpose of the visit. Administrator currently holds certificate #7019104740 Expires:12/10/2025. The facility’s fire clearance was approved for 6 non-ambulatory residents.

LPA toured facility with Liezyl including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (6) total bedrooms which four (4) bedrooms are occupied by the residents and two (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 71 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 115.0 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 were in operating condition during visit. Fire extinguisher was last serviced on 10/13/2023. Emergency Disaster Plan was last posted on 10/11/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/11/2024.

Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGELS CARE HOME
FACILITY NUMBER: 075601522
VISIT DATE: 01/02/2025
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Continued from LIC809

LPA reviewed six (6) residents records. LPA reviewed three (3) staff records and (3) of (3) have current first aid training and associated to the facility.

LPA requested the following documents to be submitted to CCLD by 01/09/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (last page)
· Liability Insurance


LPA observed the following deficiency:

At 12:46PM LPA observed during record review two (2) out of three (3) staff members didn't have the yearly eight (8) hours of in-service training documented in files..

The following deficiency were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiency by POC date and/or any repeat deficiencies within a 12-month period may result in additional Civil Penalties.


Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/02/2025 02:09 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/02/2025 at 01:35 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGELS CARE HOME
FACILITY NUMBER: 075601522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)
§1569.626 Advertising for special care, special programming, or a special environment for elderly with dementia; training requirement

(b) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time..........

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 not having two (2) out of three (3) staff members documented eight hours of in-service training per year on the subject of serving residents with dementia which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator agreed to have staff complete the required hours of training and send a self certifying email to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2025


LIC809 (FAS) - (06/04)
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