019200531-5-1-2025-15-AS-HHUL-DGFKN8-20250507080242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200531
Report Date: 05/01/2025
Date Signed: 05/01/2025 03:28:05 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
03/14/2024 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240314102857

FACILITY NAME:	ANGELS WINDSOR HOUSE		FACILITY NUMBER:	019200531
ADMINISTRATOR:	HAIDIE BAUTISTA		FACILITY TYPE:	740
ADDRESS:	2741 HILLEGASS AVENUE		TELEPHONE:	(510) 845-1850
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94705
CAPACITY:	15	CENSUS: 15	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Nelson Juta, House Manager Haidie Bautista, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff neglecting care of resident.

INVESTIGATION FINDINGS:

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On 5/1/2025 at 10:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with House Manager, Nelson Juta and explained the purpose of the visit.

During the course of investigation, LPA interviewed 4 residents, 3 staff, witness, and complainant. LPA also obtained and reviewed staff schedule, staff list with contact information, emergency information, physician's report, IPP, needs and service plan, and care notes.

Interview with residents revealed that staff would assist residents with showers. R3 stated that staff are good and treats residents equally. Interview with staff indicated there are both female and male staff working at the facility. Facility schedule showed there are 3 staff working at the facility. After reviewing R1's progress notes, R1 had routine visits with the doctors and when R1 had a change in condition. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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-20240314102857

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 WINDSOR HOUSE	FACILITY NUMBER: 019200531
	VISIT DATE: 05/01/2025

NARRATIVE

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Interview with W1 indicated R1 has lived at the facility for about 15 year and R1 have not expressed concerns to W1 about R1's care provided by facility staff.

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 is UNSUBSTANTIATED.

Exit interview conducted with Haidie Bautista over the phone. Administrator was not able to be at the facility and authorized house manager, Nelson Juta to sign CCLD reports. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

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