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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441151
Report Date: 08/25/2021
Date Signed: 08/25/2021 01:24:19 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210518091350
FACILITY NAME:ANGELEON CARE HOMEFACILITY NUMBER:
011441151
ADMINISTRATOR:DE LEON, RICHARDFACILITY TYPE:
740
ADDRESS:2124 ASHBY AVENUETELEPHONE:
(510) 704-8319
CITY:BERKELEYSTATE: CAZIP CODE:
94705
CAPACITY:12CENSUS: 11DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Danilo "Sonny" Villar, CaregiverTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was inappropriately touched while in care

Staff are threatening resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/25/2021 a 11:45AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes conducted and unannounced visit to deliver complaint findings for the above allegations. LPAs met with Danilo "Sonny" Villar, Caregiver and explained the purpose of the visit.

During the course of the investigation, LPA conducted interviews with staff, residents, R1, and obtained and reviewed records. LPA interviewed five (5) of the eleven (11) residents and three (3) staff. Based on the allegation resident was inappropriately touched while in care and staff threatening resident, LPA interviewed R1 and was not able to ascertain any names of staff or other persons that touched or threatened R1. R1 stated that she was touched all over and threatened via phone, smoke detector, and in person.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20210518091350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGELEON CARE HOME
FACILITY NUMBER: 011441151
VISIT DATE: 08/25/2021
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 LIC9099.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210518091350

FACILITY NAME:ANGELEON CARE HOMEFACILITY NUMBER:
011441151
ADMINISTRATOR:DE LEON, RICHARDFACILITY TYPE:
740
ADDRESS:2124 ASHBY AVENUETELEPHONE:
(510) 704-8319
CITY:BERKELEYSTATE: CAZIP CODE:
94705
CAPACITY:12CENSUS: DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Danilo "Sonny" Villar, CaregiverTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is not provided a comfortable enviornment

Staff are not providing adequate food service

Staff are not providing adequate activities

Staff left resident in soiled bedding
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/25/2021 at 11:45AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes conducted and unannounced visit to deliver complaint findings for the above allegations. LPA met with Danilo "Sonny" Villar, Caregiver and explained the purpose of the visit.

During the course of the investigation, LPA conducted interviews with staff, residents, R1, and obtained and reviewed records. On the allegation resident is not provided a comfortable environment. The temperature in the facility shows 68 degrees F. LPA toured facility including five (5) of the residents’ bedrooms, including R1’s bedroom, 2 bathrooms, and backyard. All were clean, sanitary, and there were no obstructions.

Continued on LIC9099C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210518091350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANGELEON CARE HOME
FACILITY NUMBER: 011441151
VISIT DATE: 08/25/2021
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 LIC9099.

On the allegation staff are not providing adequate food service. LPA collected the facility menu dated 4/26/2021 to 6/13/2021. The menu showed a variety of foods being served. LPA toured the kitchen and there was more than 7-day non-perishables and 2-day perishables for the residents.

On the allegation staff are not providing adequate activities. LPA obtained activity schedule from facility. The activity schedule included bingo, movies, garden walks, and grocery help. Documents and interview with R1 indicated that R1 goes into the community walking and shopping without assistance.

On the allegation staff left resident in soiled bedding. Interviews and documents indicated R1 conducts own ADLs without any assistance from staff. S2 stated that linens are changed weekly and comforter and blankets are washed bi-weekly or more often if needed.

This agency has investigated the complaint on the above allegations, we have found that the complaint was UNFOUNDED, meaning that the allegations was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.



Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4