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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200741
Report Date: 11/02/2022
Date Signed: 11/02/2022 04:15:11 PM

Document Has Been Signed on 11/02/2022 04:15 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'S LOVE RCFEFACILITY NUMBER:
079200741
ADMINISTRATOR:BADEO, MARCELINA M.FACILITY TYPE:
740
ADDRESS:281 PUEBLO DRIVETELEPHONE:
(925) 876-0605
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 2DATE:
11/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Marcelina Badeo, AdministratorTIME COMPLETED:
04:25 PM
NARRATIVE
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On 11/2/2022 at 2:25PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 10/20/2022. LPA met with Marcelina Badeo, Administrator and explained the purpose of the visit.

Incident report for R1 was sent via email to LPA on 10/21/2022 for an AWOL. S1 stated that R1 went outside to smoke a cigarette and left the facility approximately 11:00PM. S1 stated there was one (1) staff and three (3) residents at the facility during the incident. S1 stated that R1 normally goes out to smoke a cigarette and staff will look out window to check on R1. During interview with S2 it was stated that he went to check on R1 in his room at approximately 11PM and R1 was not there. S2 was the only staff working that night of the incident. Physician's report dated 3/8/2022 and appraisal needs and services plan dated 3/23/2022 both indicate that R1 is not able to leave facility unattended and needs supervision. During record review LPA observed R1's file was incomplete. LPA reviewed and obtained the following documents: Admission agreement; appraisal needs and services plan, LIC500, Physician's report date 3/8/2022, and the Pittsburg Police Department case number.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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'S LOVE RCFE
FACILITY NUMBER: 079200741
VISIT DATE: 11/02/2022
NARRATIVE
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Continued from LIC809.

LPA observed the following deficiencies:

-LPA observed R1's file was incomplete.
-LPA observed on R1's physician's reported it stated R1 was not able to leave facility unassisted.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

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

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 11/02/2022 04:15 PM - It Cannot Be Edited


Created By: Laura Hall On 11/02/2022 at 03:40 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: ANGEL'S LOVE RCFE
FACILITY NUMBER: 079200741

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2022
Section Cited
CCR
87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident... readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification that regulation 87506 has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.
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Based on record review and observation the Licensee did not comply with the section cited above in having a complete file for R1, which poses a potential health and safety risk to persons in case.
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Type B
11/09/2022
Section Cited
CCR87705(c)(4)

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87705 (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s... safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by:

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Administrator agreed to submit a written plan of correction stating what plan will be implemented to prevent an AWOL from occurring again. Plan will be submitted to CCLD by POC date.
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Based on LPAs interviews and record review the Licensee did not comply with the section cited above in supporting R1's needs, which poses a potential health and safety risk to residents in care.
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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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022


LIC809 (FAS) - (06/04)
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