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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200741
Report Date: 06/30/2023
Date Signed: 06/30/2023 04:45:18 PM

Document Has Been Signed on 06/30/2023 04:45 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: 6DATE:
06/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Rhonette Santos, Co-AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 6/30/2023 at 4:10pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Rhonette Santos, Co-Administrator, and explained the reason for the visit.

While LPA L. Hall was conducting a complaint investigation (15-AS-20230628124500) on 6/30/2023. During interview with S1 it was stated that R1 had AWOL'ed and that S1 did not submit an incident report.

Upon arrival LPA observed camera monitor watching a bedroom. LPA inquired with S3 which room they were watching and he stated R2.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period 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: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/30/2023 04:45 PM - It Cannot Be Edited


Created By: Laura Hall On 06/30/2023 at 04:20 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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2023
Section Cited
CCR
87211(a)(1)

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87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events... This requirement was not met as evidence by:
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Co-Administrator agreed to submit incident report for AWOL to CCLD by POC date.
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Based on LPA's interview and record review the Licensee did not comply with the seciton cited above in reporting and AWOL, which poses a potential health and safety risk to persons in care.
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Type B
07/10/2023
Section Cited
CCR87468.2(a)(1)

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87468.2 (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement was not met as evidence by:
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Staff immediately removed monitor from kitchen counter top. Deficiency cleared during visit.
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Based on LPA's observation the Licensee did not comply with the section cited above in resident having privacy in personal accommodations, which poses a potential health and safety risk to persons 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: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023


LIC809 (FAS) - (06/04)
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