331880544-5-18-2025-18-AS-RORN-DGWN9K-20250522101604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880544
Report Date: 05/17/2025
Date Signed: 05/18/2025 03:52:45 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
09/09/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240909145521

FACILITY NAME:	ANGELA'S CARE HOME		FACILITY NUMBER:	331880544
ADMINISTRATOR:	ANGELA ZHANG		FACILITY TYPE:	740
ADDRESS:	13247 SUNBIRD DR		TELEPHONE:	(951) 653-0652
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	6	CENSUS: 6	DATE:	05/17/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Ying Zi Zhang		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not prevent a resident from wandering at the facility.

INVESTIGATION FINDINGS:

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On May 17, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit to gather information regarding the above allegations. LPA met with Ying Zi Zhang, Licensee and Administrator, and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #3 (S1-S3), resident members #1 to #7 (R1-R7), and witness #1 (W1). List of documents reviewed/obtained Register of Faciltiy Residents LIC 9020, Personne Report (dated 05/09/25), (R1-R7)'s Physicians Report LIC 602 (dated 01/05/23, 01/20/23, 06/14/23, 09/01/24, 01/06/25, 02/20/25, 03/17/25, and 03/18/25), Admissions Agreement (dated 01/05/23, 04/19/23, 02/16/23, 3/17/23, and 03/18/23), and other records pertinent to this complaint.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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)

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Control Number 18-AS-20240909145521

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 #1: Staff do not prevent a resident from wandering at the facility.

The complaint states that the facility staff prevented a resident from wandering. It is reported that Resident #2 (R2) wandered into Resident #1 (R1) without permission and invaded (R1)’s space and privacy. Further reports indicated that (R2) wandered into the room and went through (R1’s) personal property, tampering with the refrigerator and television. No additional details regarding this matter were provided.

On September 16, 2024, October 04, 2024, and May 17, 2025, between 09:30 AM and 04:30 PM, the Department interviewed resident members identified as Resident #1 through Resident #7 (R1-R7). Six (6) out of the seven (7) resident members could not validate this allegation. (R1) denied the allegation, asserting that it is false. (R2) rejected the claim and confidently stated that (R2) does not recall interacting with (R1). (R3- R6) asserted that they respect each other’s personal space and prioritize their privacy. (R7) was interviewed but could not converse due to a health condition.

On September 16, 2024, and May 17, 2025, between 09:00 AM and 04:30 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) staff members could not support this allegation. (S1-S3) The residents have Major Neurocognitive Disorder (major NCD). Occasionally, individuals may momentarily lose track of their designated room, but they will be quickly and effectively guided to the correct location. This confusion is completely understandable and not intentional.

On May 09, 2025, between 04:48 PM and 05:07 PM, the Department interviewed the witness member identified as Witness #1 (W1), the family representative for (R1). (W1) confirmed that (R1) was a former Angela's Care Home resident until September 2024 and was transitioned to a skilled nursing home. (R1) required 24/7 care. (W1) who reported was unable to support this allegation. (W1) stated that the dedicated staff truly prioritized (R1) 's well-being, providing excellent care and attentive supervision without concerns.

After reviewing the Physician's Report LIC 602A for (R1-R7) 's (dated 01/05/23, 01/20/23, 06/14/23, 09/01/24, 01/06/25, 02/20/25, 03/17/25, 03/18/25) revealed that (6) out of (7) (R1-R6) all did not have wandering issues. Further review of (R1-R7) 's Admissions Agreement (dated 01/05/23, 04/19/23, 02/16/23, 3/17/23, and 03/18/23) revealed that, listed on page 23, all residents acknowledge Personal Rights.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 3

Control Number 18-AS-20240909145521

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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A review of staff training topics included Alzheimer’s Disease and related disorders, caring for patients with a change in mental status, activities of daily living (ADLs) and behaviors, challenging behaviors, and Basic Essentials.

During the visit on May 16, 2025, the Department identified that the facility promotes the rights of its residents. To improve the environment, the facility posted the Resident Rights, Personal Rights, the California Residential Care Facilities for the Elderly Complaint Poster, and the California Long Term Ombudsman Poster. This helps residents know their rights and feel good about their living situation.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

The Department was unable to conduct a follow-up interview with Resident #1 (R1) because the resident passed away on May 4, 2025, while in care at Rancho Bellagio Post Acute.

The department made several attempts to contact the family representative for Resident #3 (R3), but none of the calls were returned.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is determined Unsubstantiated.

An exit interview was conducted with caregiver Elicia Alvarez, and copies of the report were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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)

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