198600180-4-13-2022-28-AS-LHIS-CEHGUL-20220517053916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600180
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:43:51 PM

Unsubstantiated

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 Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220404105132

FACILITY NAME:	ANGELINA HOME AND CARE III		FACILITY NUMBER:	198600180
ADMINISTRATOR:	ADELINA B. ESGUERRA		FACILITY TYPE:	735
ADDRESS:	3036 LA PUENTE ROAD		TELEPHONE:	(909) 598-8323
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	6	CENSUS: 5	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Rosana Flordeliza, Staff		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff did not safeguard resident’s belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with staff Rosana Flordeliza. Administrator Adelina Esguerra was explained the purpose of the visit and interviewed telephonically.

The investigation consisted of: LPA toured the interior and exterior physical plant. Staff (S1-2) and clients (C1-C6) were interviewed. House Rules, client roster, LIC 500 Personnel Report, and C2's file documents (Appraisal Needs and Services Plan, Face Sheet, and Physician's Report were obtained.

Allegation: Staff did not safeguard resident’s belongings. It is alleged that former client (C1's) food items i.e. coconut milk/water, juice, and water bottles were being stolen by other client in care. Based on interviews conducted it was confirmed that Client (C2) has taken other clients' food items [juice, water bottles, and snacks] from the shared refrigerator in the kitchen, and/or other client rooms.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220404105132

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 III	FACILITY NUMBER: 198600180
	VISIT DATE: 04/13/2022

NARRATIVE

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continuation of Allegation: Staff did not safeguard resident’s belongings.

Administrator stated that clients are aware and reminded by staff that they cannot take other client's belongings without permission. According to staff interviews, the facility provides food, beverages, and snacks, but does not purchase water bottles. A water pitcher is always stored in the refrigerator for clients' consumption. However, clients often purchase their own beverages like soda, water bottles, coconut water/milk and store in the shared refrigerator. It is alleged that former client (C1's) coconut water/milk was being taken without permission by former roommate/client (C2). Client interviews confirmed that C2 has a tendency of taking other client's beverages or food. C2 denied taking C1's items. However, per C2's Physician Report the client is mentally and developmentally disabled. Therefore, has confirmed behavior of taking others' belongings. Former client (C1) stated "For a while I would get very upset, but now I learned that it is part of their mental illness." Two out of six clients reported that Administrator and staff are aware that C2 takes other clients' items, but do not address the incidents with C2. Interviews revealed that former client (C1) on several occasions also took others food and beverages. Client interviews revealed that staff safeguard resident's belongings, remind clients' not to take others items without permission, and acknowledged that the kitchen shared refrigerator should not be locked. Based on interviews conducted and document review, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore all the allegation is UNSUBSTANTIATED.

An exit interview was conducted with staff Rosana Flordeliza. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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