011441151-12-13-2023-15-AS-KHOS-CZ5PZE-20240103104525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011441151
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:51:34 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
10/11/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20231011134232

FACILITY NAME:	ANGELEON CARE HOME		FACILITY NUMBER:	011441151
ADMINISTRATOR:	DE LEON, RICHARD		FACILITY TYPE:	740
ADDRESS:	2124 ASHBY AVENUE		TELEPHONE:	(510) 704-8319
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94705
CAPACITY:	12	CENSUS: 9	DATE:	12/13/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Danilo "Sonny" Villar, Care Staff		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility failed to assist resident in a timely manner due to short staffing

INVESTIGATION FINDINGS:

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On 12/13/23 at 2:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a complaint investigation in regard to the allegation above. LPA spoke with Administrator, Richard DeLeon and informed him the reason for visit. Administrator gave permission for Danilo "Sonny" Villar, Care Staff to sign the report.

During the course of investigation, LPA reviewed the staff schedule and staff notes for the week of October 1-7, 2023. LPA also interviewed S1 and the Administrator.

Staff notes revealed that R1 was found on the floor of his room on 10/5/23 at 9:45 a.m. and 3:25 p.m. After the unwitnessed fall at 3:25 p.m. 911 was called. Paramedics arrived and assessed R1. Paramedics determined R1 did not need to go to the emergency room. LIC624 was filed according to regulation.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

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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Control Number 15-AS-20231011134232

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: 12/13/2023

NARRATIVE

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***report continues from 9099***

Review of the staff schedule for the week of October 1, 2023 showed that there were 2 staff on duty from 7 a.m. until 7 p.m. and 1 staff on duty from 7 p.m. until 7 a.m. All of the residents at this facility are considered to be independent.

This agency has investigated the complaint. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC9099 (FAS) - (06/04)

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