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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005151
Report Date: 11/03/2022
Date Signed: 11/03/2022 12:39:37 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Jenifer Tirre
COMPLAINT CONTROL NUMBER: 22-AS-20220823115200
FACILITY NAME:ANGIE'S HOMEFACILITY NUMBER:
306005151
ADMINISTRATOR:HO, DUNG VANFACILITY TYPE:
735
ADDRESS:1401 S JEFFERSON AVETELEPHONE:
(714) 733-9552
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:6CENSUS: 1DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Don HoTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility is allowing client to smoke in non-designated smoking areas
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Jenifer Tirre and Alvaro Ramirez conducted an unannounced visit to the facility for the purpose of delivering findings for the investigation of a complaint filed against the facility on 9/2/2022. LPA's met with Administrator/Licensee Don Ho.

During investigation LPA reviewed files, toured facility, made observations and conducted interviews with staff and clients. Based off the information obtained during investigation the following are the complaint findings.
Regarding the allegation Facility is allowing client to smoke in non-designated smoking areas, based off interviews and observations the department has found that facility has a designated smoking area which is located outside in the back corner of back yard. All Staff and Clients interviewed confirmed that one client including the client themselves smokes at the facility. Based off interviews 2 of 3 clients and 2 of 2 staff all confirmed where designated smoking area is located. All parties interviewed confirmed that Client 1 who smokes, smokes in designated smoking area. Client 1 no longer resides at facility as of 9/12/2022.

CONTINUED ON LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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 22-AS-20220823115200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGIE'S HOME
FACILITY NUMBER: 306005151
VISIT DATE: 11/03/2022
NARRATIVE
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 This agency has investigated the complaint alleging that facility is allowing client to smoke in non-designated smoking areas, although the allegation may have happened or is valid , there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator/Licensee Ho and copy of report along with a LIC 811 was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2