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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 11/21/2024
Date Signed: 11/21/2024 06:27:49 PM

Document Has Been Signed on 11/21/2024 06:27 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 CARE HOMEFACILITY NUMBER:
079201134
ADMINISTRATOR/
DIRECTOR:		WANG, DINGFACILITY TYPE:
740
ADDRESS:1723 LIMEWOOD PLACETELEPHONE:
(925) 635-3936
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY: 6CENSUS: 5DATE:
11/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:35 PM
MET WITH:Ding Wang, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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On 11/21/2024 at 4:35pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Ding Wang, Administrator, and explained the reason for the visit.

While LPA L. Hall was conducting a complaint investigation 15-AS-20241120130942 on 11/21/2024. During tour of facility LPA observed the following deficiencies.
  • LPA observed, a reverse door knob on room # 5 was locked and R1 was inside.
  • LPA observed room #6 door was locked, when open LPA observed (S4) male sitting on the bed in room
  • LPA observed during record review R1 did not have an admission agreement, consent for medical treatment, and emergency contact and identification.
  • LPA observed during record review facility did not report hospitalization for R1.
  • LPA observed during review of R1's medication that three (3) medication was missing.

*An immediate civil penalty of $250.00 will be assessed on today's date for a repeat violation and $200.00 for fingerprint. A total of $450.00.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 CARE HOME
FACILITY NUMBER: 079201134
VISIT DATE: 11/21/2024
NARRATIVE
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Continued from LIC809.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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, LIC421FC, LIC421BG, and this report.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/21/2024 06:27 PM - It Cannot Be Edited


Created By: Laura Hall On 11/21/2024 at 05:13 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 CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2024
Section Cited
CCR
87468.1(a)(6)

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(a) Residents... shall have all of the following personal rights: (6) To... not be locked into any room... by day or night. This does not prohibit a licensee... locking doors at night to protect residents... This requirement was not met as evidence by:
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Administrator agreed to have a new door knob placed without a lock or reverse the door knob with the lock being inside the room for resident.
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Based on observation the Licensee did not comply with the section cited above in R1 having a reversed door knob and being locked inside bedroom, which poses a potential health and safety risk for persons in cae.
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Type B
12/02/2024
Section Cited
CCR87506(b)

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(b) Each resident’s record shall contain at least the following information:
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Administrator agreed to obtain admission agreement, consent for medical treatment, emergency contact and identification, and submit forms to CCLD by POC date.
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Based on LPA record review the licensee did not comply with the section cited above in having R1's file completed, which poses a potential health and safety risk for 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2024 06:27 PM - It Cannot Be Edited


Created By: Laura Hall On 11/21/2024 at 05:43 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 CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2024
Section Cited
CCR
87465(d)

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(d) If the resident is unable to determine his/her own need for a prescription or nonprescription... and is unable to communicate... facility staff ... shall be permitted to assist the resident with self-administration provided all of the following requirements are met: This requirement was not met as evidence by:
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Administrator agreed to obtain medication for and submit a copy of the prescription and the bottle of medication to CCLD by POC date
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Based on observation the Licensee did not comply with the section cited above in having 3 prescribed medications available for R1 for administration which poses a potential health and safety risk to persons in care.
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Type B
11/25/2024
Section Cited
CCR87211(a)(1)

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(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 and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidence by:
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Administrator agreed to submit an LIC624 for R1's hospitalization to CCLD by POC date.
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Based on record review and interview the Licensee did not comply with the section cited above in report R1's hospitalization, 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2024 06:27 PM - It Cannot Be Edited


Created By: Laura Hall On 11/21/2024 at 05:54 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 CARE HOME
FACILITY NUMBER: 079201134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87355(d)

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(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidence by:
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Administrator agreed to get S4 fingerprinted or submit document stating S4 will not be residing in the facility to CCLD by POC date.
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Based on record review and interview the Licensee did not comply with the section cited above in have a S4 residing in facility with a clearance, which poses an immediate 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: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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