079201134-8-22-2023-15-AS-KHOS-CVCSXL-20230904141606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201134
Report Date: 08/22/2023
Date Signed: 08/22/2023 01:45:05 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
08/18/2023 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230818114650

FACILITY NAME:	ANGEL CARE HOME		FACILITY NUMBER:	079201134
ADMINISTRATOR:	WANG, DING		FACILITY TYPE:	740
ADDRESS:	1723 LIMEWOOD PLACE		TELEPHONE:	(925) 635-3936
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94553
CAPACITY:	6	CENSUS: 2	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Daisy Belen, Caregiver		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff not maintaining a comfortable room temperature for residents

Facility air conditioning is in disrepair

INVESTIGATION FINDINGS:

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On 8/22/2023 at 10:15am, Licensing Program Analyst (LPA) L. Hall to conduct an initial 10-day complaint visit and to deliver complaint findings for the allegations above. LPA met with Daisy Belen, Caregiver. Administrator, Wang Ding, arrived at 11:14am, and LPA explained the purpose of the visit.

During the course of the investigation LPA spoke with S1 and R1. LPA heard R2 stating that it was very warm in the room yesterday. LPA observed the thermometer for the facility read 78 degrees F. upon arrival. S2 was not able to turn on air conditioning unit. S1 arrived and turned on air conditioning unit and LPA observed the unit was working. S1 stated that on 8/15/2023, the air switch located in garage was only half-way on so the cool air was not blowing. S1 called the repairman to fix it and he arrived at 8pm.

Continued on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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-20230818114650

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 CARE HOME	FACILITY NUMBER: 079201134
	VISIT DATE: 08/22/2023

NARRATIVE

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Continued from LIC9099.

R1 stated during interview that he feels comfortable at this time and at night he feels a breeze through his open window. R2 also stated there was a problem with the air conditioning unit that involved a switch.

S1 also stated the resident that was transported to the hospital arrived at the facility on 8/15/2023, and left the same day. S1 did not have any paperwork for resident and stated the resident was never admitted.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights, and this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230818114650

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 CARE HOME	FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/23/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be...in good repair at all times. ...maintenance services and procedures for the safety and well-being of residents... This requirement was not met as evidence by:	1 2 3 4 5 6 7	The administrator had repairman fix switch on 8/15/2023 for the unit to blow cool air. Deficiency cleared during visit.
	8 9 10 11 12 13 14	Based on observation the Licensee did not comply with the section cited above in having the air conditioning unit operable which posed a potential health and safety risk for persons in care.	8 9 10 11 12 13 14
Type B 08/29/2023 Section Cited CCR 87303(b)(2)	1 2 3 4 5 6 7	87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.	1 2 3 4 5 6 7	Administrator had air conditioning unit switch repaired on 8/15/2023. Deficiency cleared during visit.
	8 9 10 11 12 13 14	Based on observation the Licensee did not comply with the section cited above in having a comfortable temperature in the bedrooms, which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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