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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800986
Report Date: 08/26/2022
Date Signed: 08/26/2022 02:44:21 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
07/27/2022 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20220727085343
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: 4DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Lenimar Sabate- StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee does not give residents their P&I funds.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made a subsequent visit to the facility to conduct a complaint investigation regarding the above-mentioned allegation. LPA Maldonado met with direct support professional (DSP) Virginia Wilson and explained the purpose of the visit. Staff Lenimar Sabate arrived shortly after to assist with the visit, and was also explained the purpose for the visit.

On 08/04/22, LPA Maldonado made an intial visit and requested a copy of client and staff roster, and reviewed files for Clients#1-6 (C1-C6) and Staff#1-4 (S1-S4). Interviews were also conducted with C1, and S1-S3. Copies of the following documents were also requested for C1-C6: Client's Safeguard Cash Resources to reflect Personal and Incidental funds (P&I) distribution/handling, consent to be Client's payee for Supplemental Security Income (SSI), and faceheets.

During today's visit, LPA interviewed C4.
(Report continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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 3
Control Number 28-AS-20220727085343
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: 08/26/2022
NARRATIVE
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A telephone interview was conducted with C2-C3 due clients being out of the facility at the time.

Allegation: Licensee does not give residents their P&I funds.
After review of client files for C1-C4, it was discovered that the licensee is the representative payee for (1) of (4) residents and the licensee is responsible for handling C2's P&I funds. During interviews conducted with C1-C4, (2) of (4) clients stated that they have knowledge of C2 not receiving their P&I funds in the past. C2 states C2 requested their money before, but previous administrator did not issue C2 their money when requested. Per C2's physician's report, C2 is able to handle C2's own cash resources.

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, Chapter 1, and could be found on the LIC9099-D.

An exit interview was conducted with staff Lenimar Sabate and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220727085343
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: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
CCR
80026(i)(3)
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80026 Safeguards for Cash Resources...
(i)... a client, all of his/her cash resources entrusted to the licensee and not kept in the licensed facility shall be deposited in any type of bank... meeting the following requirements:(3) The licensee shall provide access to the cash resources upon demand by the client...
This requirement was not met as evidenced by:
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The licensee will fax LPA proof of bank statements/ledgers/receipts for every deposit and/or withdrawl of cash resources for the client by the POC due date of 09/02/2022. The licensee will also include and maintain these records in the client's file.
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Based on file review, observations, and interviews, the licensee failed to ensure that clients received P&I funds when requested. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3