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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200741
Report Date: 12/07/2023
Date Signed: 12/07/2023 04:27:20 PM

Document Has Been Signed on 12/07/2023 04:27 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:
12/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Reymund Tulabot, CaregiverTIME COMPLETED:
04:35 PM
NARRATIVE
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On 12/7/2023 at 2:05pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 12/4/2023. LPA met with Reymund Tulabot, Caregiver. Administrator arrived at 2;35pm and LPA explained the purpose of the visit.

S1 called and spoke with LPA on 12/4/2023 regarding the incident and followed up with an incident report the same day. During telephone conversation with S1 it was stated that S4 was a volunteer at the facility and gave the wrong plate containing crushed medication in pureed food to R1. LPA checked guardian in the regional office and observed that S4 was not associated to the facility. Upon arrival S3 answered the door. LPA checked guardian and observed S3 was not associated to the facility. During visit LPA called the regional office to verify if both S3 and S4 were fingerprinted and it was confirmed they were not. LPA reviewed R1 and R2's file and both physician's reports did not indicate any special diet and only one showed meat should be cut. There was not any other documentation for food preparation.

LPA obtained the following for R1 and R2 during visit: admission agreement; physician's report, appraisal needs and services plan, facility roster, and staff roster.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGEL'S LOVE RCFE
FACILITY NUMBER: 079200741
VISIT DATE: 12/07/2023
NARRATIVE
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Continued from LIC809.

LPA cited for the following:
  • S3 and S4 not fingerprinted or associated to facility.
  • Camouflaging medication without consent.
  • Medical assessment not indicating any special diet or food preparation.


*An immediate civil penalty of $700.00 will be assessed on today's day for both S3 and S4 not being fingerprinted or associated to facility*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. 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 the appeal rights, LIC421BG, and this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/07/2023 04:27 PM - It Cannot Be Edited


Created By: Laura Hall On 12/07/2023 at 03:48 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: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2023
Section Cited
CCR
87355(d)

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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement under penalty of perjury. This requirement was not met as evidence by:
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Administrator agreed to get S3 and S4 fingerprinted and submit document of completion to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having S3 and S4 fingerprinted and associated which poses an immediate health and safety risk to persons in care.
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Type B
12/15/2023
Section Cited
CCR87458(b)(4)

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87458 Medical Assessment (b) The medical assessment shall include, but not be limited to: (4) Identification of physical limitations of the person... provided by the licensee, including any medically necessary diet limitations. This requirement was not met as evidence by:
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Administrator agreed to obtain documentation to puree food for R1 and R2 and submit documentation to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having consent to puree food for R1 and R2 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: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/07/2023 04:27 PM - It Cannot Be Edited


Created By: Laura Hall On 12/07/2023 at 04:04 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: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited
CCR
87465(a)(5)(D)

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87465 (a) A plan for incidental medical... care shall be developed by each facility. The plan shall encourage routine medical... (5) Facility staff... Assistance with self administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent...
This requirement was not met as evidence by:
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Administrator will obtain order to crush and camoflauge medication for both R1 and R2 and submit documentation to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in not hiding medication in food 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: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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