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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600911
Report Date: 04/26/2022
Date Signed: 04/26/2022 11:38:32 AM

Document Has Been Signed on 04/26/2022 11:38 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ANGEL HAVENFACILITY NUMBER:
415600911
ADMINISTRATOR:GIUSTO, FERLENEFACILITY TYPE:
740
ADDRESS:1660 WOLFE DRIVETELEPHONE:
(650) 458-6166
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 6DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Caregiver, Joel QuizonTIME COMPLETED:
11:45 AM
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On April 26, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted on the front door. LPA met with Caregiver, Joel Quizon and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, face coverings, daily monitoring for residents and staff, and 30-day PPE supply. LPA observed the COVID-19 signage posted throughout the facility. Bathrooms are equipped with liquid soap, paper towels, and trash cans are covered with lids. LPA advised caregiver to ensure that there are no bar soaps in the bathroom and to keep paper towels instead of hand-towels.

LPA observed 2 day perishable and 7 day non-perishable. Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present.

Garage was observed to be locked and inaccessible to residents. In the garage, LPA observed extra food supply. Washers and dryers were observed to be in good working repair and all toxins were locked.

The following updated forms are requested to be submitted to CCLD by 5/3/2022:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC400 Resident Cash Resources
-Administrator Certificate
-LIC610E Emergency Disaster Plan

Report is reviewed with caregiver and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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