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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607962
Report Date: 03/14/2022
Date Signed: 03/14/2022 10:54:35 AM

Substantiated


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
03/08/2022 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220308123850
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:
03/14/2022
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Joel Basilio (Caregiver)TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not following Covid-19 protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation to the facility. Upon arrival, LPA met with Joel Basilio (Caregiver) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the staff and resident roster and interviewed Staff #1. Upon entry into the facility, Staff #1 did not provide LPA with a temperature check, did not ask LPA to sign in or wash or sanitize hands. Witness also indicate that during an unannounced visit to the facility on 12/17/21, staff neglected to provide witness with COVID-19 screening and symptoms check. Interview with staff #1 indicate that training was provided to conducted COVID-19 protocols and symptom check but thought that LPA and Witness was exempted from COVID-19 screening.

Based on LPA's interview and observations, the investigation revealed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Joel Basilio and a copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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-20220308123850
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities
(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by: Upon entry into the facility, Staff #1 did not provide LPA with a temperature check,
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Licensee shall provide additional training to all staff regarding COVID-19 protocols and symptom screening to all visitors and provide proof to the department by the POC date.
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did not ask LPA to sign in or wash or sanitize hands. Witness also indicate that during an unannounced visit to the facility on 12/17/21, staff neglected to provide witness with COVID-19 screening and symptoms check.
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Note: LPA advised all staff present at time of visit to follow COVID-19 protocol.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2