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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880544
Report Date: 05/17/2025
Date Signed: 05/17/2025 05:00:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2023 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231206090929
FACILITY NAME:ANGELA'S CARE HOMEFACILITY NUMBER:
331880544
ADMINISTRATOR:ANGELA ZHANGFACILITY TYPE:
740
ADDRESS:13247 SUNBIRD DRTELEPHONE:
(951) 653-0652
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 6DATE:
05/17/2025
UNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Jin Zizi-LicenseeTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff assists residents with medication without proper training.
Facility records are not properly maintained.
Residents are not provided a variety of foods.
INVESTIGATION FINDINGS:
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On 5/17/2025 at approximately 8:00 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Jin Zizi/Licensee. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#2), Resident’s interviews (R#1-R#6) and Witness 1 Interview. LPA obtained and reviewed the following documents: Resident Roster dated: 4/26/25, Staff Roster dated: 5/9/25, (R#1-R#6) Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated: 3/15/25, 3/17/25, 1/6/25, 2/21/25, 7/30/23, (R#1-R#6) Admissions Agreement dated: 2/16/2023, 5/15/2023, 4/19/2023, 4/20/23, 1/15/23, and 3/18/25, (R#1-R#6) Client/Resident Personal Property and Valuables or LIC 621 dated: dated: 2/16/2023, 5/15/2023, 4/19/2023, 4/20/23, 1/15/23, and 3/18/25, Facility Staff Annual Medication In-service training sheet dated: 2/28/2025, Health and Safety check of facility food supply.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2025
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 5
Control Number 18-AS-20231206090929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELA'S CARE HOME
FACILITY NUMBER: 331880544
VISIT DATE: 05/17/2025
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff assists residents with medication without proper training

The details of the complaint alleged that facility staff does not have the proper training to give medications to the residents in care.



On May 17, 2025, at approximately 1:00 PM, during a records review, LPA Iniguez observed that the latest Facility Staff Annual Medication In-service training sheet was done on 2/28/2025.

On May 17, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that the person who dispenses medication is herself and (S#2). In addition, (A#1) stated that the facility staff and she were trained in medication management every year.

On May 17, 2025, at approximately 10:00 AM, during interviews with residents (R#1-R#6), 5 five out of 6 stated that they take their medications as prescribed by their physician. Also, (5) out of (6) stated that they think the facility staff is trained on how to manage and dispense medication.

On May 17, 2025, at approximately 11:40, LPA Iniguez could not speak with (R#5) due to cognitive impairment.

On May 17, 2025, LPA Iniguez contacted (W#1), the spouse of (R#5), three times; however, (W#1) did not return LPA Iniguez's phone call.

On May 17, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#2), (2) out of (2) stated that (A#1 and S#2) give their prescribed medications to the residents in care. In addition, (2) out of (2) facility staff stated that they received training regarding managing and dispensing medication every year.
Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20231206090929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELA'S CARE HOME
FACILITY NUMBER: 331880544
VISIT DATE: 05/17/2025
NARRATIVE
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Allegation: Facility records are not properly maintained.

The details of the complaint alleged that licensee does not have facility staff records properly maintained.



On May 17, 2025, at approximately 2:00 PM, during a physical tour of the facility, LPA Iniguez observed that the resident files were stored inside a file cabinet that can be locked in privacy. In addition, LPA Iniguez observed that the resident’s file was well-organized and properly kept.

On May 17, 2025, at approximately 1:00 PM, during a records review, LPA Iniguez observed (R#1-R#6) files well-kept and organized by facility staff.

On May 17, 2025, at approximately 8:30 AM, during an interview with the Administrator (A#1), she stated that they kept the records inside a file and locked them at the facility. Also, (A#1) stated that the residents’ records are very organized.

On May 17, 2025, at approximately 11:00 AM, during interviews with residents (R#1-R#6), (5) out of (6) stated that they think the facility staff kept their personal files properly.

On May 17, 2025, at approximately 11:40, LPA Iniguez could not speak with (R#5) due to cognitive impairment.

On May 17, 2025, LPA Iniguez contacted (W#1), the spouse of (R#5), three times; however, (W#1) did not return LPA Iniguez's phone call.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20231206090929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELA'S CARE HOME
FACILITY NUMBER: 331880544
VISIT DATE: 05/17/2025
NARRATIVE
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On May 17, 2025, at approximately 10:00 AM, during interviews with facility staff (S#1-S#2), 2 two out of 2) stated that stated that the residents’ files are being kept locked in a file cabinet. Also, (2) out of (2) facility staff stated that the residents’ records are well-kept and organized.

Allegation: Residents are not provided a variety of foods.

The details of the complaint alleged that facility does not offer a variety of foods to the residents in care.



On May 17, 2025, at approximately 2:00 PM, during a physical tour of the facility's kitchen and pantry, LPA Iniguez observed a variety of food items such as bread, frozen meats, dairy products, eggs, vegetables, cereals, and can products that meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.

On May 17, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that the facility offers different kinds of food items, such as meats, vegetables, and carbohydrates, to the residents in care.

On May 17, 2025, at approximately 11:00 AM, during interviews with residents (R#1-R#6), (5) out of (6) stated that the facility offers them a variety of food, such as meat, vegetables, and carbohydrates.

On May 17, 2025, at approximately 11:40, LPA Iniguez could not speak with (R#5) due to cognitive impairment.

On May 17, 2025, LPA Iniguez contacted (W#1), the spouse of (R#5), three times; however, (W#1) did not return LPA Iniguez's phone call.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20231206090929
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELA'S CARE HOME
FACILITY NUMBER: 331880544
VISIT DATE: 05/17/2025
NARRATIVE
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On May 17, 2025, at approximately 10:00 AM, during interviews with facility staff (S#1-S#2), (2) out of (2) stated that the facility offers different kinds of food items, such as meats, vegetables, and carbs, to the residents in care

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of the Complaint Report was given to Jin Zizi/Licensee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5