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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200741
Report Date: 04/18/2024
Date Signed: 04/18/2024 05:48:48 PM

Document Has Been Signed on 04/18/2024 05:48 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/
DIRECTOR:		BADEO, MARCELINA M.FACILITY TYPE:
740
ADDRESS:281 PUEBLO DRIVETELEPHONE:
(925) 876-0605
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 4DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Marcelina Badeo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 04/18/2024 at 1:45PM, Licensing Program Analysts LPAs L. Hall and L. Holmes conducted an unannounced Annual 1-year required inspection. LPAs met with Administrator, Marcelina Badeo, and explained the reason for the visit. The administrator currently holds a certificate (#6035565740) that expires on 06/02/2025. The facility’s fire clearance was approved for five (5) Non ambulatory and one (1) Bedridden residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) bedrooms and three (3) bathroom. Two (2) bedrooms are occupied by staff. LPA observed pool in the back yard is inside a locked fence. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPAs 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 at 106.4 degrees Fahrenheit. Night lights are maintained in hallways and passages. Residents’ bathrooms are equipped with grab bars no and non slip mats

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/30/2024. Emergency Disaster Plan was last posted on 09/02/2023. First aid kit was observed to be complete. Fire drill was last conducted on 6/10/2022.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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: 04/18/2024
NARRATIVE
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Continued from LIC809C
  • LIC 610E Emergency Disaster Plan
  • Residents roster
  • Updated facility sketch for patio room and door for #6
  • Liability Insurance
  • LIC308 Designation of facility responsibility
  • LIC500 Personnel record


LPAs observed the following deficiencies:
  • At 2:10pm, LPAs observed during record review R3 and R4's files are not completed.
  • At 3:00pm, LPAs observed during record review S3 did not have health screening or TB test.
  • At 3:00pm, LPAs observed facility did not have 7-days perishables and 2 days non perishable food supply.
  • At 3:55pm, LPA observed wooden planks, shovels, pruner, home defense, paint rollers, and a gallon paint in backyard.

Deficiencies 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 the appeal rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/18/2024 05:48 PM - It Cannot Be Edited


Created By: Laura Hall On 04/18/2024 at 05:14 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having complete records for R3 and R4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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3
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Administrator will complete records for R3, R4, and submit self-certification that records are complete to CCLD by POC date.
Type B
Section Cited
CCR
87555(26)
87555 General Food Service Requirements

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in have a supply of 7-day non-perishables and 2-day perishable for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Administrator agreed to purchase food and submit photo of food and receipts to CCLD by POC date.
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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/18/2024 05:48 PM - It Cannot Be Edited


Created By: Laura Hall On 04/18/2024 at 05:21 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services

(d) The following space and safety provisions shall apply to all facilities:

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having passageways free of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Administrator agreed to remove all items and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in have S4 a health screening and TB test prior to working which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Administrator agreed to have S4 obtain a health screening and TB test and submit a copy to CCLD by POC date.
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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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