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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441151
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:55:27 PM

Unsubstantiated


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
05/03/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240503130411
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:
06/12/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Danilo "Sonny" Villar, Care Staff TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident is financially abused.
INVESTIGATION FINDINGS:
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On 05/16/24 around 04:45 PM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to deliver the complaint finding. LPA was greeted by one (1) Care Staff. LPA telephoned Richard De Leon, Administrator and explained the purpose of the visit. Danilo "Sonny" Villar, Care Staff will sign the report.

During the investigation, LPA toured the room of Resident (R2), interviewed R1, and Staff (S2 and S3). LPA requested the following records: LIC 400 Affidavit Regarding Client/Resident Cash Resources, LIC 500, Resident Roster, ID/Emergency contact sheet, Admission Agreements and most recent Physician Reports for Residents (R1, R2, R3 & R4).

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 2
Control Number 15-AS-20240503130411
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: 06/12/2024
NARRATIVE
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...continued from LIC9099.

Allegation: Resident is financially abused.

Based on record reviews of Admission Agreements, ID/Emergency Information, LIC 400 Affidavit Regarding Client/Resident Cash Resources, and interviews with Staff (S1, S2 and S3), Witnesses (W1), and an interview with Resident (R1), there was no mention of financial abuse or documentation of financial abuse presented to LPA. R1 Although R1 provided the complaint findings from (15-AS-20210518091350), none of the allegations were related to financial abuse. W1 stated that she/he does not know how financial abuse would work for R1 because R1 is not working.

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



Exit interview conducted. A copy of this report provided to Staff, Danilo "Sonny" Villar.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2