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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201134
Report Date: 09/14/2023
Date Signed: 09/14/2023 01:52:45 PM

Unsubstantiated


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
09/11/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20230911111248
FACILITY NAME:ANGEL CARE HOMEFACILITY NUMBER:
079201134
ADMINISTRATOR:WANG, DINGFACILITY TYPE:
740
ADDRESS:1723 LIMEWOOD PLACETELEPHONE:
(925) 635-3936
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 2DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mary Lorraine Adriatico, CaregiverTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff handled resident in a rough manner which resulted in a fall

Staff did not treat resident with dignity and respect
INVESTIGATION FINDINGS:
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On 9/14/2023 at 12:00pm, 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 Mary Lorraine Adriatico, Caregiver. Wang Ding ,Administrator, arrived at 12:44pm, and LPA explained the purpose of the visit.

During the course of the investigation LPA interviewed staff and both residents. S1 stated there was a resident that had moved in for one (1) day, but did not have any paperwork. S1 also stated the resident went to the hospital the same day and has now moved to another facility. S2 stated she did not recall the name of the resident that had been admitted. Both residents stated they have not had any problems with any of the staff and they are treated well.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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 2
Control Number 15-AS-20230911111248
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: 09/14/2023
NARRATIVE
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Continued from LIC9099.

Based upon the interviews during the investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2