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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880544
Report Date: 06/30/2023
Date Signed: 06/30/2023 12:12:14 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
06/23/2023 and conducted by Evaluator Jesse Gardner
COMPLAINT CONTROL NUMBER: 18-AS-20230623101311
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:
06/30/2023
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Licensee Angela ZhangTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Licensee initated Hospice Care without notifying Responsible Party
Facility did not meet the resident's needs
Facility failed to meet incontinent care
Facility failed to report incidents as required
Facility failed to dispense medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analsyt (LPA) Jesse Gardner conducted an unannounced visit to commence a complaint investigation into the above allegations. LPA identified himself and discussed the purpose of the visit, and elements of the allegations with Licensee Angela Zhang.

It was alleged that staff initiated hospice care for Resident One (R1) without notifying R1's responsible party. Through interview with the Licensee, Licensee confirmed that they contacted Hospice to begin services for R1. Interview further revealed that the Licensee did not contact R1's responsible party. Thus, this allegation was Substantiated.

Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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 5
Control Number 18-AS-20230623101311
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: 06/30/2023
NARRATIVE
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It was then alleged that upon R1's admission to the hospital, R1 did not arrive with any documents to let hospital staff know what what going on with R1. Upon LPA inspection, LPA found that there was no care plan developed for R1, nor additional records. The Licensee did not develop a care plan to address the needs for R1; thus this allegation was Substantiated.

It was then alleged that after R1 left for the hospital, R1's bed was still wet three days after R1 had been admitted. On June 13, 2023, R1's bed was reportedly leaking with urine. Upon inspection of R1's room, and bed, LPA asked the Licensee about the pungent urine smell. Further, LPA inspected R1's mattress which was on a hospice bed, and LPA discovered black stains on the top of the mattress. Hospice staff interview revealed that R1 was on hospice for approximately 4 days. Licensee interview revealed that R1 would often release their bowels, and spread urine all over the room from the bed, to the floor, and that R1's incontinence was difficult to manage. Through LPA observation, staff interview, and hospice staff interview, LPA found that this allegation was Substantiated.

It was then alleged that the facility failed to report incidents to the Department as required per Title 22. Interview with Licensee revealed that when R1 went to the hospital on June 10, 2023, and then further on June 13, 2023 when R1 passed away, an Unusual Incident Report was not sent to the Department; thus this allegation was Substantiated.

It was then alleged that the facility failed to dispense medication as prescribed. Due to the lack of records, and Licensee indicating that they have no record of R1's medication, nor, the dispensing of their medication; this allegation was Substantiated.

An exit interview was conducted where a copy of this report was provided along with copies of the LIC9099C, LIC9099D, and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20230623101311
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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
87468.1(a)(16)
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Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(16) To receive or reject medical care or other services. This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training on the cited regulation, and will provide proof of training with all staff by POC date.
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Based on LPA interview with Licensee, Licensee indicated that they contacted Hospice to intiate services for R1. This is a potential personal rights risk for residents in care.
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Type B
07/07/2023
Section Cited
CCR
87633(h)(4)
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Hospice Care of Terminally Ill Residents:(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan approved by the licensee, the hospice agency, and the resident, or the resident’s Health Care Surrogate Decision Maker if the resident is incapacitated. This requirement was not being met as evidenced by:
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Licensee reported that R1 is no longer in care within the facility to develop new records. Licensee agrees to conduct in-service training on the cited regulation and submit by POC date.
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Based on document review, and LPA observation, and staff interview, R1 did not have any records related to the needs, and care that R1 had received by the Licensee. This is a potential health and safety risk to residents in care.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230623101311
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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
87625(b)(3)
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Managed Incontinence:(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training on the cited regulation, and provide proof of such by POC date.
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Based on observation and staff interview, LPA found that R1 had incontinent challenges and those needs were not being met by Licensee. This is a potential personal rights risk to residents in care.
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Type B
07/07/2023
Section Cited
CCR
87211(a)(1)(A)
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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement was not being met as evidenced by:
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Licensee agrees to submit the death report and hospital visit for R1 by COB on June 30, 2023. Further, Licensee agrees to conduct in-service training with staff regarding the cited regulation. This will be submitted by POC date.
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Based on staff interview, Licensee indicated that the death report for R1 was not submitted to the Department. This is a potential health and safety risk to residents in care.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20230623101311
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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
87506(d)
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Resident Records(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement was not being met as evidenced by:
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Licensee agrees to ensure a complete record is maintained for each resident. Licensee further agrees that in-service training will be conducted for all staff including Licensee on the maintenance of records. This training is due by POC date.
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Based on the lack of resident record for R1, Licensee could not prove that R1's records were being dispensed as required. This is a potential health and safety risk for residents in care.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5