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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802313
Report Date: 08/03/2023
Date Signed: 08/03/2023 12:44:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/02/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20221102111400
FACILITY NAME:ANGELINA HOME AND CARE IIFACILITY NUMBER:
197802313
ADMINISTRATOR:ESGUERRA, ADELINAFACILITY TYPE:
735
ADDRESS:622 N. WATERBURY AVENUETELEPHONE:
(626) 257-3245
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 5DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Lucita Atanacio - Caregiver TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff mismanages clients’ medication
Facility has an infestation of roaches
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent visit at the facility regarding the above allegations. LPA met with Lucita Atanacio caregiver and explained the reason for the visit.

The investigation consisted of the following: On 11/10/22 LPA Irra conducted an initial investigation visit and requested a copy of staff/client roster. On 8/3/23 LPA Flores conducted a tour of facility's kitchen, 3 client rooms, 1 staff room, living room, 2 bathrooms, and back yard. LPA interview clients #1-#2 (C1-C2) and staff #1(S1). LPA reviewed medication for 3 clients, and 2 client files.

The investigation revealed the following: Regarding allegation Staff mismanages clients' medication. It is alleged staff provides discontinued medications by the clients’ doctor to clients in care.

(CONTINUED LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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 5
Control Number 28-AS-20221102111400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME AND CARE II
FACILITY NUMBER: 197802313
VISIT DATE: 08/03/2023
NARRATIVE
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 Interviews with clients revealed 1 client state to refuse to take medications often and 1 client has noticed there is a confusion when medications are discontinued but has not cause problems or miss ups on medication for the client. Staff stated medication is provided to the clients and when they refuse or is discontinued the medication is stored in "an envelope" as overflow and does not get disposed through the pharmacy. Upon reviewing box of additional overflow medication LPA observed 5 medications for C3 with expiration dates 6/4/23 and 6/10/23. Based on medication reviewed during today's visit facility did not properly disposed of expired medication.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding allegation: Facility has an infestation of roaches. It is alleged facility has had an infestation of roaches for the last 6 months. Interviews with clients revealed 2 out of 2 clients interview have observed roaches at the facility, specially in the kitchen. Staff stated that the home is currently under exterminator treatment. LPA observed a roach crawling in the table during the medication review.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted with caregiver and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/02/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20221102111400

FACILITY NAME:ANGELINA HOME AND CARE IIFACILITY NUMBER:
197802313
ADMINISTRATOR:ESGUERRA, ADELINAFACILITY TYPE:
735
ADDRESS:622 N. WATERBURY AVENUETELEPHONE:
(626) 257-3245
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 5DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Lucita Atanacio - Caregiver TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Due to a language barrier staff can’t communicate with clients
Facility is malodorous
Staff do not provide clean linens to clients
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent visit at the facility regarding the above allegations. LPA met with Lucita Atanacio caregiver and explained the reason for the visit.

The investigation consisted of the following: On 11/10/22 LPA Irra conducted an initial investigation visit and requested a copy of staff/client roster. On 8/3/23 LPA Flores conducted a tour of facility's kitchen, 3 client rooms, 1 staff room, living room, 2 bathrooms, and back yard. LPA interview clients #1-#2 (C1-C2) and staff #1(S1). LPA reviewed medication for 3 clients, and 2 client files.

Regarding allegation: Due to a language barrier staff can’t communicate with clients. It is alleged staff speaks limited English and because of that staff can’t communicate properly with the clients.

(CONTINUED LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20221102111400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ANGELINA HOME AND CARE II
FACILITY NUMBER: 197802313
VISIT DATE: 08/03/2023
NARRATIVE
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Interviews with clients revealed 2 out of 2 clients interview stated to be able to communicate with staff and not have difficulties meeting their needs due to communication. Staff was able to understand and answer LPA questions during the visit. Staff provided information, medication, and toured as LPA requested during the visit.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.


Regarding allegation: Facility is malodorous. It is alleged facility has a strong odor of urine. Interviews with 2 out of 2 clients stated facility does not have urine odors. Staff stated there are clients that required incontinence care. File review determined clients do have bladder issues. During the tour, LPA did not perceived bad odors or urine in any of the rooms or bathrooms.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.


Regarding allegation: Staff do not provide clean linens to clients. It is alleged when clients urinate on themselves, the staff don’t provide them clean bedding because they are only allowed to do laundry once a week. Interviews with clients 2 out of 2 clients stated linens are provided and they wash them on their assigned laundry day, once a week. Staff stated linens are change as needed. During the visit LPA observed linens were clean and additional linens were observed stored in a hallway closet.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted with caregiver and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20221102111400
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELINA HOME AND CARE II
FACILITY NUMBER: 197802313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
80075(l)
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80075 Health Related Services: (l) Prescription medications.., or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client.
This requirement is not met as evidence by:
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Adiministrator is to properly destroyed the medication that are refused/or expired and maintain the centrally store/destruction sheet and submit a copy of the form to the department by POC due date 8/10/23.
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Based on observation and interviews conducted licensee did not ensure to properly destroy medication for C3 which poses a potential risk to the health, safety, or personal rights to the persons in care.
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Type B
08/10/2023
Section Cited
CCR
80087(a)(1)
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80087 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidence by:
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Administrator will provide proof of contract with an exterminator company to the department by POC due date 8/10/23 and will continue to provide services as needed for infestation and provide proof to the deparment for next six (6)months.
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Based on observation and interviews conducted facility did not ensure to keep faciltiy free of roaches which poses a potential risk to the health, safety, or personal rights to the 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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5