331880544-7-28-2023-18-AS-JESL-CUYVAN-20230823161610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880544
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:25:50 PM

Substantiated

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
07/28/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230728094943

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: 7	DATE:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Angela Zhang, Licensee/Administrator		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Licensee abandoned resident at hospital
Licensee did not distribute resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner and Licensing Program Manager (LPM) Joel Esquivel met with Licensee/Administrator Angela Zhang (S1) in the CCL ASC Riverside Regional Office to investigate the above allegations. The investigation was held at the office due to a previous meeting scheduled with Zhang at the office.

It was alleged that the Licensee/ Administrator Angela Zhang took Resident #1 (R1) to the hospital on 07/27/2023, and refused to pick up or bring back R1 to the facility. LPA conducted an interview with the licensee who stated that the hospital initially provided funding to R1 for one month. R1's funding was not provided to the Licensee beyond one month. When hospital staff contacted Licensee on 07/27/2023 to pick up R1, Licensee explained to the hospital

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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-20230728094943

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/04/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	PERSONAL RIGHTS (a)..each client shall have personal rights which include..(3)..withholding of shelter.. This requirement is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to pick up R1, and review regulation. Licensee to conduct in-service training to staff including themselves and provide proof of such by POC date.
	8 9 10 11 12 13 14	Based on LPA interviews, Licensee did not provide R1 the means to have shelter. This poses a potential health and safety risk and personal rights to residents in care.	8 9 10 11 12 13 14
Type B 08/04/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct in-service training for all staff, including themselves on the cited regulation and provide proof of such by POC date.
	8 9 10 11 12 13 14	Based on interview with Licensee, Licensee did not maintain R1's care when R1 ran out of medications and was out of medications for approximately 1 week. This is a potential health and safety and/or personal rights risk for residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230728094943

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: 07/28/2023

NARRATIVE

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that the Licensee was worried about funding. The licensee wanted the hospital to pay for the current and additional months of rent since the family had not paid as promised.

Based on this fact that the licensee dropped off the resident at the hospital, refused to pick up the resident for the lack of payment the allegation that the resident was abandoned at the hospital is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation, Licensee did not distribute resident's medication as prescribed.
It was further alleged that Licensee was not dispensing medication as prescribed. Interview with Licensee indicated that R1 lived at the facility for approximately one month. On the second month the licensee knew that R1 was out of medication, but failed to seek medication refill because as she stated "she was way to busy getting the file ready for the LPA so that she would not get cited". R1 was without medication for one week and was thereafter dropped off at the hospital for lack of payment.

Based on this fact that the licensee dropped off the resident at the hospital, and failed to refill the resident medication as required that allegation that the licensee failed to dispense medications as prescribed is thereby substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was provided to Licensee/Administrator Angela Zhang along with copies of the LIC811, LIC9099-D, and Appeal Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

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