331880544-5-18-2025-18-AS-RORN-DGVL62-20250521082802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880544
Report Date: 05/18/2025
Date Signed: 05/18/2025 12:45:02 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 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:	05/18/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Jin Zizi/Licensee		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident's dietary needs were not met by facility staff.
Staff did not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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On 5/18/2025 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: 05/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025

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 4

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: 05/18/2025

NARRATIVE

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Investigation Revealed the Following:

Allegation: Resident's dietary needs were not met by facility staff.

The detail of the complaint alleges that facility does not offer meal substitutes for residents in care.

On May 17, 2025, at approximately 1:00 PM, during a records review, LPA Iniguez observed the Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A. The reports were dated March 15, 2025; March 17, 2025; January 6, 2025; February 21, 2025; and July 30, 2023. Among the reviewed records, only (R#2, R#3, and R#5) had a special diet indicated on the form, while (R#1, R#4, and R#6) did not have any special diet noted.

On May 17, 2025, at approximately 8:30 AM, during an interview with the Administrator (A#1), she stated that they provide a variety of foods to accommodate residents' dietary needs, including diabetic diets and low-salt diets. Additionally, (A#1) mentioned that there are currently (3) residents in care who require special diets (R#2, R#3 and R#5).

On May 17, 2025, at approximately 11:00 AM, during interviews with residents (R#1-R#6), (3) out of (6) stated that they have special diet requirements, and the facility staff has successfully accommodated their needs. In addition, (2) out of (6) residents in care stated they do not have any special diet requirements.

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: 05/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 05/18/2025

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 they offer different kinds of foods to meet residents' dietary needs, such as diabetic diet, low salt, etc. Also, (2) out of (2) facility staff stated that they only have (3) residents in care with special diets (R#2, R#3 and R#5).

Allegation: Staff did not safeguard resident's personal belongings.

The detail of the complaint alleges that facility staff is not safeguarding residents’ personal belongings.

On May 17, 2025, at approximately 9:00 AM, during a records review, LPA Iniguez observed (R#1-R#6)’s 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. All forms were completed and filed by facility staff.

On May 17, 2025, at approximately 8:30 AM, during an Interview with the Administrator (A#1), she stated that they try their best to safeguard all residents ' personal belongings.

On May 17, 2025, at approximately 11:00 AM, during interviews with residents (R#1-R#6), (5) out of (6) stated that their personal belongings are being kept safe by the facility. In addition, (5) out of (6) residents in care stated that they feel safe living here.

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: 05/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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: 05/18/2025

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 safeguard all residents personal belongings.

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: 05/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2025

LIC9099 (FAS) - (06/04)

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