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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607962
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:37:48 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2022 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20220707163449
FACILITY NAME:QUEEN OF THE ANGELS ASSISTED LIVING INC.FACILITY NUMBER:
197607962
ADMINISTRATOR:TERRY & MARY MCGEEFACILITY TYPE:
740
ADDRESS:420 S. MANNINGTON PLACETELEPHONE:
(626) 430-7702
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
07/13/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Joel Basilio TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not wear masks.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Wong and Ya Ting Yang conducted a complaint visit to investigate the allegation: Staff do not wear masks. LPA met with staff member Joel Basilio and explained the reason for the visit. A short time later, administrator, Terry McGee arrived.

The investigation consisted of the following: LPAs interviewed 6 residents and families, two staff and administrator and reviewed residents' documents/files.

The investigation revealed of the following: Allegation "Staff do not wear masks." LPA interviewed 6 residents and five out of six residents denied the allegation and reported the staff always wears mask while they are working. The staff are very causious and follow the Covid 19 protocol. LPA interviewed staff and they reported they both are live in staff. They do wear mask when they serve the residents or provide direct care to the residents such as feeding or showering them. LPAs also observe staff are wearing mask during our complaint investigation. (See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
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 28-AS-20220707163449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: QUEEN OF THE ANGELS ASSISTED LIVING INC.
FACILITY NUMBER: 197607962
VISIT DATE: 07/13/2022
NARRATIVE
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Based on interviews conducted with residents and staff and LPA's observation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of the report and appeal right was provided to caregiver Joel Basilio
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2