<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201134
Report Date: 02/13/2025
Date Signed: 02/13/2025 01:52:32 PM

Document Has Been Signed on 02/13/2025 01:52 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:
02/13/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Rosalita Constantino, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/13/2025, at 1:15PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Rosalita Constantino, Caregiver and explained the purpose of the visit.

LPA conducted a case management visit on 1/30/2025 and cited for the following deficiency that has been corrected.

  • 87303(e)(5), LPA observed shared bathroom and private bathroom in master bedroom have non skid mats.

LPA conducted a case management visit on 1/30/2025 and cited for the following deficiencies that has not been corrected.
  • 87307(3)(c), LPA observed facility does not a sufficient supply of linen and towels for residents. LPA observed 4 flat sheets, 0 fitted, a beach towel and one (1) bath towel, five (5) comforters, a lot of pillow cases and hospital blankets.
  • 87211(a)(1), LPA observed that incident reports for R1 and R2 was not submitted for their hospitalization.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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
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: 02/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

*LPA arrived to amended the report to reflect $100.00 should have been $700.00*
  • Each uncorrected deficiency is $700.00 x 2 = $1400.00.

Civil Penalties in the total amount of $1400.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies are corrected.

Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2