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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200744
Report Date: 06/01/2023
Date Signed: 06/01/2023 07:20:40 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
05/26/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230526114818
FACILITY NAME:ANGEL WINGS CARE HOME IFACILITY NUMBER:
079200744
ADMINISTRATOR:LOIDA PENAFACILITY TYPE:
740
ADDRESS:1403 PREWETT RANCH DRIVETELEPHONE:
(510) 329-4926
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 3DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Rose Acholonu, AdministratorTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Staff use a metal stick on the front door to keep residents from exiting the facility
Staff are not trained
Staff mismanaged resident's medications
INVESTIGATION FINDINGS:
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On 06/01/23 at 5:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

Allegation: Staff used a metal stick on the front door to keep residents from exiting the facility
Investigation Finding: Substantiated
During investigation, staff (S1) confirmed with LPA that witness (W1) visited the facility on 05/22/23 and that staff used a metal stick on the top left part of the front door to keep residents from exiting (photos have been included). 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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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 4
Control Number 15-AS-20230526114818
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 I
FACILITY NUMBER: 079200744
VISIT DATE: 06/01/2023
NARRATIVE
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Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff used a metal stick on the front door to keep residents from exiting the facility was found to be substantiated.

Allegation: Staff are not trained
Investigation Finding: Substantiated
During investigation, LPA observed facility's emergency/disaster record was last updated on 01/01/2022 with an outdated list of staff/contacts information. On 05/30/23, witness (W1) confirmed with LPA that staff (S1) did not have knowledge on how to access residents’ emergency contacts/responsible persons records. LPA observed resident's (R1, R2, R3) medication administration records dated 06/01/23 were left blank when prescribed medications were administered in the morning. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff are not trained was found to be substantiated.

Allegation: Staff mismanaged resident’s medications


Investigation Finding: Substantiated
During investigation, LPA confirmed with staff (S1) that on 05/22/23, witness (W1) observed staff (S1) did not have knowledge of resident (R1)’s prescription medications. Witness (W1) stated that R1’s administration records were not filled out when VA nurse visited on 05/17/23. LPA also observed R1, R2 and R3 medication administration records for June 1, 2023 was left blank after medications were administered to residents in the morning (photos have been included). Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff are not trained was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. 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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20230526114818
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 I
FACILITY NUMBER: 079200744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87468.1(a)(6)
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To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night…
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By POC due date, Administrator agreed to submit to CCL written self-certification that staff has read, understood and will comply with Title 22 Section 87468.1 to ensure that residents can leave or depart the facility at any time and not to be locked into any room, building or on facility premises by day or night.
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This requirement was not met as evidenced by staff used a metal stick to prevent residents from exiting the facility front door which posed a potential health & safety risk to residents in care.
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Type B
06/23/2023
Section Cited
CCR
87461(f)(2)
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Emergency care requirements shall include the following: (2) The name, address and telephone number of each emergency agency to be called in the event of an emergency, including but not limited to the fire department, crisis center or paramedical unit or medical resource, shall be posted in a location visible to both staff and residents.
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By POC due date, Administrator agreed to submit to CCL written self-certification that staff has read, understood and will comply with Title 22 Section 87461 to ensure that residents’ records are readily available for review and reference by staff, licensing inspections and third party agencies.
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This requirement was not met as evidenced by staff not having knowledge of how to access residents’ emergency contacts/responsible persons records when asked which posed a potential safety risk to residents 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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20230526114818
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 I
FACILITY NUMBER: 079200744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87465(a)(6)
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When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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By POC due date, administrator agrees to complete and submit to CCLD in-service staff retraining certifications on timely medication administration in compliance with Title 22 Section 87465 incidental medical and dental care regulations.
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This requirement was not met as evidenced by staff (S1) did not have knowledge of resident (R1)’s prescription medications which posed a potential health & safety risk to residents 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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4