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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 01/30/2025
Date Signed: 01/30/2025 05:21:41 PM

Document Has Been Signed on 01/30/2025 05:21 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: 4DATE:
01/30/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rosalita Constantino, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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On 1/30/2025 at 10:00am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an text message that was sent to LPA on 1/14/2025. LPA met with Rosalita Constantino, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Ding Wang, via telephone.

The text message was from Administrator, and stated there were only three (3) residents and one (1) staff in the day and at night. LPA arrived to find there were four (4) residents and one (1) caregiver.

LPA L. Hall requested the after-summary visits for R1 and R2 to be sent to CCLD by 2/1/2025.

LPA observed the following deficiencies.
  • At 10:20am, LPA observed the facility did not have a sufficient quantity of towels for residents. LPA observed beds missing top sheet, mattress pads, and bedspread.
  • At 10:35am, LPA observed shared bathroom did not have a slip-resistant mat.
  • At 11:15am, LPA observed during record review that R1 and R1 was hospitalized and CCLD was not notified.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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: 01/30/2025
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Continued from LIC809.

*A civil penalty of $500.00 total ($250.00 each) will be assessed on today's date for repeat violations of regulations 87307(3)(c) and 87211(a)(1).*

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, 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 LIC421FC, this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/30/2025 05:21 PM - It Cannot Be Edited


Created By: Laura Hall On 01/30/2025 at 12:08 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: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/06/2025
Section Cited
CCR
87307(3)(c)

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(3) Equipment and supplies necessary for personal care... shall be readily available to each resident. (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often... clean linen is in use by residents at all times. This requirement was not met as evidence by:
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Administrator agreed to purchase towels and enough linen for each resident. Administrator will submit photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having suffiencient linen for residents, which poses a potential health and safety risk to persons in care.
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Request Denied
Type B
02/06/2025
Section Cited
CCR87303(e)(5)

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement was not met as evidence by:
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Administrator agreed to purchase non skid mat and submit photo to CCLD by POC date.
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Based on observation the Licensee did not comply wiht the section cited above in having a non slip mat in the shared bathroom tub, 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: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/30/2025 05:21 PM - It Cannot Be Edited


Created By: Laura Hall On 01/30/2025 at 12:17 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: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2025
Section Cited
CCR
87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency such reports... (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... This requirement was not met as evidence by:
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Administrator agreed to submit incident reports for R1 ad R2 to CCLD by POC date.
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Based on record review the Licensee did not comply with the section above in reporting incidents for R1 and R2 to CCLD, 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: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
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