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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800082
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:27:43 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2021 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210526085039
FACILITY NAME:ANGELIC MANORFACILITY NUMBER:
331800082
ADMINISTRATOR:MATAMOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:35490 PRAIRIE ROADTELEPHONE:
(951) 609-1646
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:6CENSUS: 6DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Michelle Matamoros, Licensee/AdministratorTIME COMPLETED:
02:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility denied access to Ombudsman.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with Licensee Michelle Matamoros and explained the purpose of the visit. This allegation was investigated by department staff.

Allegation #1: “Facility denied access to Ombudsman”. The allegation alleged that the Ombudsman was denied access to the facility on multiple visits throughout the county. The allegation alleged that the Ombudsman was badged and identified as the certified program, and was denied access by facility staff. Department staff interview with the Licensee/Administrator revealed that the Licensee/Administrator denied this allegation. The Licensee/Administrator stated that the Ombudsman representative was allowed to enter the facility. The Licensee/Administrator stated that the Ombudsman representative arrived at the facility, signed in the guest log, and dated the visit as March 26, 2021. The Licensee/Administrator stated that the Ombudsman representative was allowed to speak with the residents and spoke with some of them. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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 4
Control Number 18-AS-20210526085039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ANGELIC MANOR
FACILITY NUMBER: 331800082
VISIT DATE: 05/16/2023
NARRATIVE
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32
A finding of Unsubstantiated means 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.

An exit interview was conducted and copy of this report was provided.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2021 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210526085039

FACILITY NAME:ANGELIC MANORFACILITY NUMBER:
331800082
ADMINISTRATOR:MATAMOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:35490 PRAIRIE ROADTELEPHONE:
(951) 609-1646
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:6CENSUS: 6DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Michelle Matamoros, LicenseeTIME COMPLETED:
02:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility denied Ombudsman access to resident's records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with Licensee/Administrator Michelle Matamoros and explained the purpose of the visit. TThe investigation consisted of interviews with relevant parties.

Allegation #2 “Facility denied Ombudsman access to resident's records”. LPA Nickolas interview with the Licensee/Administrator revealed that the Licensee/Administrator admits to this allegation. The Licensee/Administrator stated that Ombudsman requested to review resident #1's (R1's) medical file. The Licensee/Administrator stated that staff #1 (S1) was unsure if they could allow the Ombudsman representative access to R1's medical file. The Ombudsman representative did not state why they needed to review R1's medical files. Licensee/Administrator stated that S1 called the Licensee/Administrator, and the Licensee/Administrator spoke with the Ombudsman representative. The Licensee/Administrator stated they asked the Ombudsman representative the purpose of their request to review R1's medical file and was not provided a reason why. The Licensee/Administrator informed the Ombudsman representative that they could not access R1’s medical files.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20210526085039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ANGELIC MANOR
FACILITY NUMBER: 331800082
VISIT DATE: 05/16/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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14
15
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32
The Licensee/Administrator stated they denied the Ombudsman presentative access to R1’s medical files because they did not obtain written consent from R1 or R1’s legal representative. The Licensee/Administrator was adhering to section 87506(c)(1) of the California Code of Regulations (CCR).

This agency has investigated the complaint allegation. We have found that the complaint was unfounded meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4