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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441151
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:30:31 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
08/19/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210819153356
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:
09/29/2021
UNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Danilo Villar, caregiverTIME COMPLETED:
02:08 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a pressure injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/29/21 at 2PM, Licensing Program Analysts (LPAs) Daisy Panlilio and Lisha Holmes arrived unannounced to deliver findings and met with administrator (ADM). LPAs explained the purpose of the visit with ADM.

During investigation, interviews with staff and resident (R1) confirmed that R1 was admitted into the facility with existing leg wounds and was refusing treatment. This department had investigated the complaint alleging that R1 sustained a pressure injury while in care . We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

No deficiencies cited. Exit Interview conducted and a copy of this report provided to ADM.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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