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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600180
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:45:03 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
04/04/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220404105132
FACILITY NAME:ANGELINA HOME AND CARE IIIFACILITY NUMBER:
198600180
ADMINISTRATOR:ADELINA B. ESGUERRAFACILITY TYPE:
735
ADDRESS:3036 LA PUENTE ROADTELEPHONE:
(909) 598-8323
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY:6CENSUS: 5DATE:
04/13/2022
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Rosana Flordeliza, StaffTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Facility window is in disrepair.
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. Pictures of the exterior physical plant were taken. Client roster and LIC 500 Personnel Report were obtained.
Allegation: Facility window is in disrepair. Based on physical plant observation and interviews conducted the findings indicate that the 2 rooms located in the front of the home have old vertical glass panels that do not seal properly, and is allowing cold and hot air inside. Three out of six clients in care confirmed the window is in disrepair. In addition, the kitchen window screen is torn. It is alleged that Administrator discourages clients from turning on the heater in order to save energy. Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D. Exit interview was conducted with staff Rosana Flordeliza. A copy of the report and appeal rights were provided.
Substantiated
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)
Page: 1 of 2
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2022
Section Cited
CCR
80088(b)
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Furniture, Fixtures, Equipment, and Supplies. All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement was not met evidenced by:
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Administrator shall replace and/or replace all the window screens that are torn or damaged. In addition, the glass panels in the front windows shall be sealed properly so that air and insects do not enter inside when the windows are closed.
Submit picture proof of corrections by POC due date.
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Based on observation and interviews conducted the kitchen window screen is torn, living room window is missing a screen, and the rooms in the front of the home that have vertical glass panels are not sealed properly, and have screens that are in disrepair.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2