<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800986
Report Date: 04/11/2022
Date Signed: 04/11/2022 08:15:21 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, 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
04/04/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20220404103700
FACILITY NAME:ANGELINA HOME & CAREFACILITY NUMBER:
197800986
ADMINISTRATOR:ESGUERRA, ADELINAFACILITY TYPE:
735
ADDRESS:250 W. GRAGMONT ST.TELEPHONE:
(626) 915-1974
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 5DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Florante Viloria, StaffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing residents with food of good quality.
Staff does not keep kitchen free from flies.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tao, conducted a unannounced complaint investigation for the allegations listed above today. During today’s visit, LPA was allowed entry by staff, Florante Viloria. LPA spoke with Licensee, Adelina Esguerra, over the phone during the visit. LPA explained the purpose of today's visit to staff and Licensee, regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #2 (S2); interviews of clients from Client#1 (C1) through Client #5 (C5); reviewed client#1’s record reviews, and a facility tour.
LPA obtained copies of the Staff and client Rosters; and resident files for Client #1 (C1) with relevant information.

The investigation revealed the following:
(-continued in LIC 9099 C-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
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 6
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
04/04/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20220404103700

FACILITY NAME:ANGELINA HOME & CAREFACILITY NUMBER:
197800986
ADMINISTRATOR:ESGUERRA, ADELINAFACILITY TYPE:
735
ADDRESS:250 W. GRAGMONT ST.TELEPHONE:
(626) 915-1974
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 5DATE:
04/11/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Florante Viloria, StaffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility bathroom is dirty.
Staff not providing a comfortable environment for resident.
Staff deprived resident of toilet paper.
Staff threaten resident.
Staff did not safeguard resident’s belongings.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tao, conducted an unannounced complaint investigation for the allegations listed above today. During today’s visit, LPA was allowed entry by staff, Florante Viloria. LPA spoke with Licensee, Adelina Esguerra, over the phone during the visit. LPA explained the purpose of today's visit to staff and Licensee, regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #2 (S2); interviews of clients from Client#1 (C1) through Client #5 (C5); reviewed client#1’s record reviews, and a facility tour.
LPA obtained copies of the Staff and client Rosters; and client files for Client #1 (C1) with relevant information.

The investigation revealed the following:
(-continued in LIC 9099 C-)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20220404103700
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: ANGELINA HOME & CARE
FACILITY NUMBER: 197800986
VISIT DATE: 04/11/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In regard to allegation: “Facility bathroom is dirty," it was alleged that the clients’ bathroom is dirty and not being cleaned. Three (3) out of five (5) clients could not corroborate the allegation. Client interviews of C2, C4 and C5 revealed that clients’ bathroom is clean and staff clean the bathroom about 3 times per week. Two (2) out of five (5) clients stated the bathroom is not clean. Interview with C1 and C3 revealed that the clients’ bathroom is dirty. Two (2) out of two (2) staff denied the clients’ bathroom is dirty and not being cleaned. LPA observed that clients’ bathroom is clean and has no foul odor during the visit.

In regard to allegation: “Staff not providing a comfortable environment for resident," it was alleged that client#1 is not allowed to turn on a portable air conditioner or heater in client's room. Five (5) out of five (5) clients stated they are allowed to turn on their portable air conditioner in their room. Since the heater is a centralized heater, staff monitors the heater; therefore, clients are not monitoring it. Staff interview revealed that staff will turn on the heater when it is needed. Two (2) out of two (2) staff denied the allegation. LPA observed that clients’ room temperature and it is at a comfortable temperature.

In regard to allegation: “Staff deprived resident of toilet paper," it was alleged that client#1 is not allowed to use the facility’s toilet paper because Client #1 has used too much of it. Four (4) out of five (5) clients could not corroborate the allegation. Client interview revealed that four (4) out of five (5) clients are allowed to use toilet papers and has no restriction on using it. Interview with C1 revealed that sometime staff would not provide client with an additional roll of toilet papers. Staff interview revealed that staff will provide clients with toilet papers and may provide more when it is needed. LPA observed that clients’ bathroom has additional toilet papers available for clients’ use.

In regard to allegation: “Staff threaten resident," it was alleged that client#1 would be evicted if client#1 uses facility’s toilet paper. Five (5) out of five (5) clients could not corroborate the allegation. All five (5) clients interviews revealed no client has been threaten with eviction of using facility toilet paper. Two (2) out of two (2) staff denied the allegation. Staff interview revealed that clients have right to use toilet paper and would not be evicted by using facility’s toilet paper.


(-continued in LIC 9099 C-)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20220404103700
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: ANGELINA HOME & CARE
FACILITY NUMBER: 197800986
VISIT DATE: 04/11/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In regard to allegation: “Staff did not safeguard resident’s belongings," it was alleged that other clients are stealing client#'1s food that client#1 purchased. Four (4) out of five (5) clients could not corroborate the allegation. Client interview from Client #2 to Client #5 revealed that clients are able to locate their purchased food and denied of their food being stolen by other clients. Interview with C1 revealed client’s purchased food was missing but could not recall the details. Two (2) out of two (2) staff denied the allegation. Staff interview revealed that staff will remind clients not to take other client’s food.

Although the allegations 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 allegations are UNSUBSTANTIATED.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Staff Florante Viloria and Licensee. A hard copy of this report was provided to staff.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20220404103700
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: ANGELINA HOME & CARE
FACILITY NUMBER: 197800986
VISIT DATE: 04/11/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
In regard to allegation: “Staff are not providing residents with food of good quality," it was alleged that facility does not offer fruits and served low quality food to clients. Five (5) out of five (5) clients stated the food quality is not good and fruits are not offered most of the time. Client interviews from C1 to C5 revealed that clients are not offered enough fruit and food variety at the facility from their meal. Two (2) out of two (2) staff denied the clients’ food quality is low and not offer fruit to clients. File review showed client’s food menu listed that fruit should be serves from each meal and food variety. However, staff interview revealed staff did not follow the food menu to provide food and fruits. LPA observed that clients’ food inventory on fruit and only observed 2 bananas on dining table, 3 oranges and 5 more bananas at the food storage area. The fruit supply is insufficient for client's dietary needs.

In regard to allegation: “Staff does not keep kitchen free from flies," it was alleged that the back door in the kitchen is left open causing flies to fly in. Five (5) out of five (5) clients stated the kitchen's back door is left open causing flies to fly in throughout the day. Client interviews from C1 to C5 revealed that the kitchen back door is left open and flies fly into the kitchen. Two (2) out of two (2) staff denied the allegation. LPA observed that the kitchen back door is left open and flies fly in and out from that door during the visit.

Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with Staff Florante Viloria and Licensee. A hard copy of this report and appeal rights were provided to staff
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20220404103700
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: ANGELINA HOME & CARE
FACILITY NUMBER: 197800986
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited
CCR
80076(a)(1)
1
2
3
4
5
6
7
Food Services (a) (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will update the food menus and provide fruit to clients per clients' diet needs. A copy of an updated menus will be faxed to Monterey Park office by POC
8
9
10
11
12
13
14
Based on observation, licensee did not provide sufficent fruit for client's diet need which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
04/20/2022
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will keep the back door close and flies from flying in the facility. Licensee will put a screen door. Licensee will send a picture of the screen door and post a sign on the door to keep the door close to Monterey Park office by POC
8
9
10
11
12
13
14
Based on observation, facility left the back door at the kitchen open and has flies to fly in facility. Licensee did not keep facility in sanitary which poses/posed a potential health, safety or personal rights 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6