198202004-8-21-2023-11-AS-MVAO-CUYS88-20230823133841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198202004
Report Date: 05/03/2023
Date Signed: 08/21/2023 02:30:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2022 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20220928172123

FACILITY NAME:	ANGELS HOME CARE		FACILITY NUMBER:	198202004
ADMINISTRATOR:	ANA GUTIEREZ LECHUGA		FACILITY TYPE:	740
ADDRESS:	28030 ACANA RD		TELEPHONE:	(310) 265-4994
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90274
CAPACITY:	6	CENSUS: 4	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Oscar Lechuga		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Licensee did not ensure the facility was appropriately staffed with personnel with qualifications adequate to perform assigned tasks

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, May 03, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Caregiver Oscar Lechuga. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker conducted interviews with staff members 1 through 3 (S1-S3). The questions posed were pertinent to the nature of the complaint. Staff members S1-S3 indicated that the facility maintains an appropriate staffing level, with personnel possessing qualifications sufficient for their assigned responsibilities. Unfortunately, LPA Bunker was unable to interview residents 1 through 4 (R1-R4) due to their nonverbal status. In lieu of direct interviews, LPA Bunker requested and subsequently reviewed both staff and residents' records. LPA Bunker request a copy of the staff timecards, personnel report LIC 500, and the staff job descriptions, and verify which staff person was on due 09/09/2022. S1-S3 stated staff are alert and did not hear anyone at the door. See continued LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 3

Control Number 11-AS-20220928172123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS HOME CARE	FACILITY NUMBER: 198202004
	VISIT DATE: 05/03/2023

NARRATIVE

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Continued LIC9099-C page 2

Allegation: Licensee did not ensure the facility was appropriately staffed with personnel qualifications adequate to perform assigned tasks
S1-S3 interviewed stated that they have the required knowledge for providing care and supervision needed to the residents. S1-S3 stated that they are given on-the-job training and have the appropriate experience which provides knowledge and skill to perform their jobs safely and effectively. S1-S3 stated that they are complying with Title 22 Regulations. S1-S3 stated the facility is fully staffed. S1-S3 stated residents are never left unattended. S1-S3 stated staff is available 24 hours a day 7 days a week 365 days a year to assist residents in care with their daily needs. S1-S3 stated the facility cannot discriminate against employees who is in a wheelchair, based on age, etc. S1-S3 stated the facility has appropriate staffed with personnel qualifications adequately to perform assigned tasks. S1-S3 denied the allegation.

Investigation revealed the following: Interviews were conducted with staff members (1-3) S1-S3. Their feedback consistently reflected that the facility maintains a commendable staffing level and that personnel possess qualifications that align effectively with their designated responsibilities. Residents (1-4) R1- R4, are nonverbal, inability to interview residents, posed a challenge in gathering their perspectives.

The facility exhibited a state of full staffing during the site visit. S1-S3 asserts that residents are consistently attended to and not left without supervision. This observation was reinforced by the active engagement witnessed between staff and residents throughout the premises. S1-S3 attested to the ongoing nature of staff training, highlighting the competence of the personnel to fulfill the diverse requirements of individual residents.

S1-S3 affirmed that on the date of September 9th, 2022, they did not encounter instances of repeated knocking at the facility's entrance, nor did they observe anyone peering through the front door or windows. The living room was identified as a shared space for television viewing by residents, as confirmed by S1-S3.

S1-S3 underscored the facility's inclusive ethos by mentioning the presence of a wheelchair-bound staff member, who plays an active role in aiding residents with placement-related needs. S1-S3 affirm their
affiliation with the facility and their clearance status, acquired through fingerprinting procedures further attest to their suitability for roles within the facility. See continued LIC9099-C page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220928172123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS HOME CARE	FACILITY NUMBER: 198202004
	VISIT DATE: 05/03/2023

NARRATIVE

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Continued LIC9099-C page 3

LPA Bunker observed the facility personnel report summary of individuals associated with the facility, and verification of fingerprint clearance was established for all staff affiliated with the facility. S1-S3 reiterated their commitment to furnishing adequate care and vigilant supervision to residents. S1-S3 denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation 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 allegation is deemed unsubstantiated.

There were no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC9099 (FAS) - (06/04)

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