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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200567
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:37:41 PM

Document Has Been Signed on 02/11/2022 02:37 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:ANGEL WINGS CARE HOME IIIFACILITY NUMBER:
079200567
ADMINISTRATOR:YABUT, ANITAFACILITY TYPE:
740
ADDRESS:5420 SAN MARTIN WAYTELEPHONE:
(925) 392-8915
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Versan Ibay, AdministratorTIME COMPLETED:
02:52 PM
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On 02/11/22 at 1:45PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 2 staff wearing face masks during visit with 5 residents watching TV while the other resident was resting inside her bedroom. Facility has a completed mitigation plan in place dated 02/12/2021 to mitigate the spread of COVID-19.

LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing.

Pathways were observed to be free of obstruction and fire hazards. Facility has a visitation area with furnitures spaced six feet apart for social distancing among residents. A written Emergency/Disaster plan dated 01/08/22 was posted near the sliding back door. Centrally stored medications were locked in cabinets. Sharp objects were locked in the kitchen drawers.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGEL WINGS CARE HOME III
FACILITY NUMBER: 079200567
VISIT DATE: 02/11/2022
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Toxic chemicals were locked in the laundry room and garage. Administrator stated a portable PPE cart is available for use outside of the isolation room. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. LPA advised administrator to replace all open trash bins with lid operated with foot pedal for the kitchen, bathrooms and bedrooms.

Infection control designated leader is the administrator. All 3 staff and 6 residents have been fully vaccinated, 1st dose 2/02/21, 2nd dose 2/23/21 Pfizer).There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 72 degrees Fahrenheit. Administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided via email to administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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