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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200331
Report Date: 04/23/2021
Date Signed: 04/23/2021 04:46:54 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
09/29/2020 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200929112301
FACILITY NAME:DREAN OF ANGEL CARE LLCFACILITY NUMBER:
079200331
ADMINISTRATOR:ANGIE ESPLANAFACILITY TYPE:
740
ADDRESS:274 STARLING WAYTELEPHONE:
(510) 313-0361
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 5DATE:
04/23/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angie EsplanaTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Resident nor responsible party signed admission agreement.
Facility failed to issue refund to resident.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla spoke with Administrator to deliver findings on the above allegations. LPA explained to the Administrator that due to the telework directive of management, this visit is being conducted via Facetime.

On 10/8/2020, LPA Rolanda Pitcher conducted 10-day visit. On 4/1/2021, LPA Luisa Fontanilla interviewed Administrator and Staff 3 (S3). On 4/8/2021, LPA L. Fontanilla interviewed Resident 1 (R1). On 4/12, LPA interviewed Staff 4 (S4). Administrator confirmed with LPA that there is no signed admission agreement and that no refund has been made to R1 yet.
Based on interview conducted , the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D.

Copy of this report and Appeal Rights will be emailed to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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-20200929112301
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: DREAN OF ANGEL CARE LLC
FACILITY NUMBER: 079200331
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited
HSC
1569.887(a)
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Signature of resident on admission agreement; copy of agreement to go to resident or resident’s representative; review
(a) The admission agreement shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative.
This requirement is not met as evidenced by:
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By POC date, Administrator will 1) review H&S Code Chapter 3.2 Article 09 on Admission Agreement and submit self certification stating understanding of provisions in Article 09 and 2) review all existing residents' admission agreement and make sure all are complete
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Based on interviews conducted, Administrator states facility does not have a signed admission agreement which poses a potential risk to health and safety of clients under care.
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Type B
05/14/2021
Section Cited
HSC
87507(5)(a)
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Admission Agreements
(A) Facility policy concerning refunds, including the conditions under which a refund ....

This requirement is not met as evidenced by:
Based on interviews and records review, facility failed to refund R1. R1 stayed at
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By POC date, Administrator states R1 will be given a refund by POC date. Administrator added R1 will be charged for the days he stayed at the facility only.
Proof of refund will be sent to LPA.
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the facility for 3 days but paid the full month's rent without any signed admission agreement which poses a potential risk to the health and safety of residents under care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
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
09/29/2020 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200929112301

FACILITY NAME:DREAN OF ANGEL CARE LLCFACILITY NUMBER:
079200331
ADMINISTRATOR:ANGIE ESPLANAFACILITY TYPE:
740
ADDRESS:274 STARLING WAYTELEPHONE:
(510) 313-0361
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 5DATE:
04/23/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angie EsplanaTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff yelled at resident.
Staff not assisting residents with ADLs.
Facility did not serve food of the quantity to meet the needs of the resident.
Facility did not safeguard the resident's belongings.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla spoke with Administrator Angie Esplana and explained that the purpose of this call is to deliver findings on the above allegations.

On 10/8/2020, LPA Rolanda Pitcher conducted 10-day visit. On 4/1/2021, LPA Luisa Fontanilla interviewed Administrator and Staff 3 (S3). On 4/8/2021, LPA L. Fontanilla interviewed Resident 1 (R1). On 4/12, LPA interviewed Staff 4 (S4).

Staff yelled at resident.

LPA interviewed Administrator and S3 who both denied yelling at R1. Both employees state that R1 is hard of hearing and staff need to speak louder than usual to be able to communicate. During LPA interview with R1 on the phone, LPA observed R1 has difficulty hearing. Even with hearing aids on, LPA had to speak louder
in order for R1 to understand.
**continuation on Lic 9099C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
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-20200929112301
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: DREAN OF ANGEL CARE LLC
FACILITY NUMBER: 079200331
VISIT DATE: 04/23/2021
NARRATIVE
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Staff not assisting residents with ADLs.
Based on R1's physician's Report and interviews conducted, R1 is independent with his ADLs. He needs assistance with medications. For showers, he only needs standby supervision, for safety. During his 3 day stay at the facility, staff interviewed states that R1 was assisted with showers and was even grateful for the help.


Facility did not serve food of the quantity to meet the needs of the resident.
Based on interviews conducted, Administrator, S3 and S4 state that R1 and all the other residents are given sufficient quantity and quality of foods. Staff denied serving R1 with noodles since facility does not purchase noodles. LPA observed there was sufficient supply of perishable and nonperishable foods during televisit. Also, LPA did not observe any noodles.



Facility did not safeguard the resident's belongings.
Based on interviews conducted, all of R1's belongings were picked up by R1's family member. One blanket was left at the facility but Administrator states that it was delivered and received by R1's family member. LPA verified and confirmed with family that the blanket was indeed received.

Based on interviews conducted and records reviewed, the above allegations are unsubstantiated.

Although the allegations may have happened or is/are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

There is no deficiency noted.

A copy of this report will be sent to Administrator via email.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4