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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802313
Report Date: 07/01/2024
Date Signed: 07/01/2024 05:04:31 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
06/24/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20240624160602
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:
07/01/2024
UNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Staff#1, caregiver (staff in charge)TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide a comfortable temperature for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation visit for the allegations listed above. During today’s visit, LPA met with staff#1. LPA spoke with house manager, Shirley Esguerra, over the phone during the visit. LPA explained the purpose of today's visit to staff#1 and Licensee.

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-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
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
Control Number 28-AS-20240624160602
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 AND CARE II
FACILITY NUMBER: 197802313
VISIT DATE: 07/01/2024
NARRATIVE
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In regard of staff did not provide a comfortable temperature for residents, it was alleged that staff did not turn on the AC resulting the facility was hot. All five (5) clients corroborated the allegation. Client interviews revealed staff would turn on the AC when the days were hot. All staff denied the allegation. Staff interview revealed clients had personal right to reside at the facility with a comfortable temperature. During the visit, the AC was on, however, only the fan was working, and the room temperature was 90.9 degree Fahrenheit. Therefore, the facility did not provide a comfortable temperature for clients at the facility.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20240624160602
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 AND CARE II
FACILITY NUMBER: 197802313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
80088(a)(1)
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(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:
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Licensee agreed to repair or replace the facility air conditioner or provide a portable air conditioner in clients’ room to keep the facility’s temperature within the range of 68 degree F and 85 degree F by the POC due date. A photo of evidence of correction will be provided to Licensing by POC due date.
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Based on observation, the licensee did not maintain. This poses a potential health and safety risk to residents
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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: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
06/24/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20240624160602

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:
07/01/2024
UNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Staff#1, caregiver (staff in charge)TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff member did not treat residents with dignity and respect.
Facility has an infestation of cockroaches and rats.
Staff did not provide adequate food service.
Staff did not provide the necessary supplies for residents' personal care.
Illegal eviction.
Staff do not supply drinking water to residents.
INVESTIGATION FINDINGS:
1
2
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5
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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation visit for the allegations listed above. During today’s visit, LPA met with staff#1. LPA spoke with house manager, Shirley Esguerra, over the phone during the visit. LPA explained the purpose of today's visit to staff#1 and Licensee.

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: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20240624160602
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 AND CARE II
FACILITY NUMBER: 197802313
VISIT DATE: 07/01/2024
NARRATIVE
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In regard of staff member did not treat residents with dignity and respect, it was alleged staff mistreated and belittled clients. Per client interviews, one (1) out of five (5) clients stated staff did not treat client with respect. Four (4) out of five (5) clients could not corroborate the allegation. Client interviews revealed staff did not speak inappropriately or mistreat clients. All staff denied the allegation. Staff interview revealed staff treated clients with respect and dignity. In addition, LPA observed that staff were nice to clients and did not belittle or disrespect clients during the time of visit. Therefore, there was not preponderance of evidence to prove staff failed to treat clients with dignity and respect.

In regard of facility has an infestation of cockroaches and rats, it was alleged the facility had an infestation of rats and cockroaches. Per client interviews, one (1) out of five (5) clients stated facility had an infestation of cockroaches and rats. Four (4) out of five (5) clients could not corroborate the allegation. Client interview revealed that the facility did not observe to have pest issues. Per staff interviews, all staff denied the allegation. Staff interview revealed the facility was in contract with pest control company and the company did not indicate the facility had pest issues. Per LPA observation, LPA did not observe dead cockroaches or rats at the facility or trace of pest issues. Thus, the facility did not observe to have an infestation.

In regard of staff did not provide adequate food service, it was alleged staff did not provide food or snacks to clients and did not allow clients to cook for themselves. Per client interviews, one (1) out of five (5) clients stated the facility did not provide adequate food to client. Four (4) out of five (5) clients could not corroborate the allegation. Client interview revealed that the facility had provided clients with food and snacks between meals. Clients chose not to cook for themselves since meals and food were provided. Per staff interviews, all two (2) out of two (2) staff denied the allegation. Staff interview revealed that staff provide three meals daily and snacks, such as fruit and breads to clients during the day. LPA conducted physical plant and reviewed food supplies. LPA observed snacks and beverages, such as cookies, crackers, soda, coffee, fruit, fruit juice, and milk. There were more than 2 days of perishable and 7 days of nonperishable food supplies at the facility. Therefore, snacks were provided to clients with adequate food services.

In regard of staff did not provide the necessary supplies for residents' personal care, it was alleged staff did not provide toilet paper, shampoo, or soap to clients to use. Per client interviews, one (1) out of five (5) clients corroborated the allegation. Four (4) out of five (5) clients could not corroborate the allegation. Client interview revealed that facility provided clients with toilet papers / soaps and had no restriction on using them. Clients could have their personal preference of hygiene supplies; thus, they used their own supplies.
(-continued in LIC 9099 C-)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20240624160602
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 AND CARE II
FACILITY NUMBER: 197802313
VISIT DATE: 07/01/2024
NARRATIVE
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Sometime staff would not provide client with an additional roll of toilet papers in the bathroom. Per staff interviews, all staff denied the allegation. Staff interview revealed staff would provide clients with toilet papers, hygiene supplies and soaps all time. Additional hygiene supplies would provide to clients when needed. LPA observed that clients’ bathroom had toilet paper in the bathroom. Additional toilet papers, soaps and hygiene supplies were observed and available for clients’ use.

In regard of illegal eviction, it was alleged that client received a 30-day eviction notices due to client drank alcohol at the facility. Per client interviews, one (1) out of five (5) clients corroborated the allegation. Four (4) out of five (5) clients could not corroborate the allegation. Client interviews revealed that clients were not aware of any eviction occurred at the facility. Per staff interview, all staff denied the allegation. Staff interview revealed that the facility had a house rule not drinking alcohol at the facility. Sometimes, client would drink and got drunk at the facility. That was a violation of house rule. Per file review, only eviction notice was provided to client and no eviction action had in process. Licensee had working with case manager at the regional center for a new placement for the client. Thus, no illegal eviction had occurred at the facility.

In regard of staff do not supply drinking water to residents, it was alleged the facility only provide tap water as drinking water. Per client interviews, one (1) out of five (5) clients corroborated the allegation. Four (4) out of five (5) clients could not corroborate the allegation. Client interviews revealed that facility provided drinking water and tap water to clients for drinking. Per staff interview, two (2) out of two (2) staff denied the allegation. Staff interview revealed that facility had provided bottled water and tap water for clients to drink. Per observation, drinking water was observed at the facility. Thus, facility had provided drinking water to clients.

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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6