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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200743
Report Date: 10/06/2023
Date Signed: 10/06/2023 05:18:27 PM

Substantiated


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
09/29/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230929120538
FACILITY NAME:ANGEL WINGS CARE HOME IIFACILITY NUMBER:
079200743
ADMINISTRATOR:SAMIA, VILMAFACILITY TYPE:
740
ADDRESS:1921 BLUE MOUNTAIN COURTTELEPHONE:
(510) 329-4926
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Anita Yabut, Administrator
Joyce Goyena, Staff		TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility did not provide an adequate assessment to resident in care
Staff do not provide proper mobility assistance to resident in care
INVESTIGATION FINDINGS:
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On 10/06/23 at 4:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (S1) and spoke with administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA gathered information and delivered investigation findings to S1 and ADM. LPA explained the purpose of the visit with ADM.

Allegation: Facility did not provide an adequate assessment to resident in care
Investigation Finding: Substantiated
During investigation, LPA interviewed staff (ADM) and witness (W1) who confirmed that resident (R1) was not adequately assessed which resulted in facility not being prepared for R1’s mobility requirements (hospital bed and hoyer lift required for daily care) prior to being admitted at the facility on 09/23/23.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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 5
Control Number 15-AS-20230929120538
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: ANGEL WINGS CARE HOME II
FACILITY NUMBER: 079200743
VISIT DATE: 10/06/2023
NARRATIVE
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ADM stated R1 was first admitted at the facility on 09/23/23 without the medical bed and hoyer lift required for her care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility did not provide an adequate assessment to resident in care. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated.

Allegation: Staff do not provide proper mobility assistance to resident in care


Investigation Finding: Substantiated
During investigation, staff (ADM, S1) and witness (W1) confirmed with LPA that resident (R1) was first admitted at the facility on 09/23/23 without the hospital bed and hoyer lift in place for R1’s use prior to admittance. R1 was sent to the hospital for UTI on 09/25/23. W1 stated hospital had to order R1’s hospital bed and hoyer lift as well as schedule home health visits for R1 when she was ready for discharge on 09/29/23. ADM stated they requested hospital to give them a few days to prepare for R1's return due to positive COVID cases at the facility. S1 stated R1's daughter removed all personal belongings on 10/01/23 and R1 did not return to the facility. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not provide proper mobility assistance to resident in care. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230929120538
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: ANGEL WINGS CARE HOME II
FACILITY NUMBER: 079200743
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
87457(c)
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Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs…
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By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on proper pre-admission appraisal for residents in compliance with Title 22 Section 87457 regulations.
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This requirement was not met as evidenced by staff failing to conduct a proper pre-placement appraisal on resident which posed a potential health & safety risk to resident in care.
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Type B
10/31/2023
Section Cited
CCR
87459(a)
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The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living…
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By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on functional capabilities in compliance with Title 22 Section 87459 regulations.
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This requirement was not met as evidenced by staff failing to provide proper mobility assistance to resident which posed a potential health & safety risk to resident in 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/29/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230929120538

FACILITY NAME:ANGEL WINGS CARE HOME IIFACILITY NUMBER:
079200743
ADMINISTRATOR:SAMIA, VILMAFACILITY TYPE:
740
ADDRESS:1921 BLUE MOUNTAIN COURTTELEPHONE:
(510) 329-4926
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Anita Yabut, Administrator
Joyce Goyena, Staff		TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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3
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9
Improper Eviction
INVESTIGATION FINDINGS:
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On 10/06/23 at 4:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (S1) and spoke with administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA gathered information and delivered investigation findings to S1 and ADM. LPA explained the purpose of the visit with ADM.

Allegation: Improper Eviction
Investigation Finding: Unsubstantiated
During investigation, witness (W1) confirmed with LPA that administrator (ADM) never issued a written notice of eviction to resident (R1) while at the facility.

Continued on next page, LIC 9099-C pg2j
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230929120538
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: ANGEL WINGS CARE HOME II
FACILITY NUMBER: 079200743
VISIT DATE: 10/06/2023
NARRATIVE
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ADM stated R1 was first admitted at the facility on 09/23/23. ADM stated R1 was sent to the hospital on 09/25/23 due to urinary tract infection (UTI). R1 was treated for UTI at the hospital and was ready for discharge on 09/29/23. ADM stated she never evicted R1. ADM stated she requested hospital to give them a few days to prepare for R1's return since they were still waiting for her medical bed and hoyer lift to arrive. ADM stated R1's family member was notified of COVID positive residents and staff at the facility. S1 stated R1's personal belongings were removed by family member on 10/01/23 and R1 did not return to the facility.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of improper eviction. 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 of improper eviction to resident is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5