079200994-6-9-2023-15-AS-KHOS-CSYGNG-20230620052931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200994
Report Date: 06/09/2023
Date Signed: 06/09/2023 04:06:04 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
05/31/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230531164718

FACILITY NAME:	ANGELS TOUCH CARE HOME, LLC		FACILITY NUMBER:	079200994
ADMINISTRATOR:	ROSS, LARUTH		FACILITY TYPE:	740
ADDRESS:	1653 SWALLOW WAY		TELEPHONE:	(510) 725-2020
CITY:	HERCULES	STATE: CA	ZIP CODE:	94547
CAPACITY:	6	CENSUS: 2	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	03:26 PM
MET WITH:	Laruth Hartwell, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff abandoned resident at hospital

INVESTIGATION FINDINGS:

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13

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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-20230531164718

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: ANGELS TOUCH CARE HOME, LLC	FACILITY NUMBER: 079200994
	VISIT DATE: 06/09/2023

NARRATIVE

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Witnesses stated that ADM refused to take resident (R1) back to the facility. On 05/31/23, ADM finally texted back stating R1 has been discharge from the facility because R1’s personal belongings were removed by family on 05/30/23.

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 abandoned resident at hospital was found to be substantiated.

Deficiency is 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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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
05/31/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230531164718

FACILITY NAME:	ANGELS TOUCH CARE HOME, LLC		FACILITY NUMBER:	079200994
ADMINISTRATOR:	ROSS, LARUTH		FACILITY TYPE:	740
ADDRESS:	1653 SWALLOW WAY		TELEPHONE:	(510) 725-2020
CITY:	HERCULES	STATE: CA	ZIP CODE:	94547
CAPACITY:	6	CENSUS: 2	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	03:26 PM
MET WITH:	Laruth Hartwell, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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9

Staff did not follow proper eviction procedures for resident

INVESTIGATION FINDINGS:

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On 06/09/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

Allegation: Staff did not follow proper eviction procedures for resident
Investigation Finding: Unsubstantiated
Based on interviews and record reviews which were conducted, witness (POA) confirmed with LPA that administrator (ADM) never issued a written notice of eviction to resident (R1) while at the facility. Review of R1’s admission agreement show R1 was admitted at the facility on 05/08/23. ADM stated R1 was sent to the hospital on 5/26/23 and did not return back to the facility. Family removed R1’s personal belongings on 05/30/23. 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 that staff did not follow proper eviction procedures to resident is unsubstantiated.
Exit interview conducted and a copy of this report provided

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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-20230531164718

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: ANGELS TOUCH CARE HOME, LLC	FACILITY NUMBER: 079200994
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2023 Section Cited CCR 87365(a)(2)	1 2 3 4 5 6 7	The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.	1 2 3 4 5 6 7	By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on proper incidental medical and dental care for residents in compliance with Title 22 Section 87465 regulations.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff abandoning resident at the hospital which posed a potential health & safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4