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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881044
Report Date: 01/05/2024
Date Signed: 01/05/2024 12:41:51 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
01/27/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230127150620
FACILITY NAME:ANGELVIEW CARE HOMES, INC. @ SAMANTHAFACILITY NUMBER:
331881044
ADMINISTRATOR:EMBALSADO, MAY BOCOFACILITY TYPE:
735
ADDRESS:23099 SAMANTHA PLACETELEPHONE:
(951) 780-4990
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:4CENSUS: 3DATE:
01/05/2024
UNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Flordeliza Gerarado, CaregiverTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Caregiver Flordeliza Gerarado and informed them of the purpose of this visit. During this investigation, LPA conducted interviews with staff and clients; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation #1 – Staff handled resident in a rough manner. Concerns were expressed that during a hospital visit, S1 reportedly yanked R1’s arm. During the interview with Staff One (S1), S1 admitted that while at the hospital, R1 went to the nurse’s station to ask where R1 could obtain a snack. The nurse’s station acknowledged the request,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
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-20230127150620
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: ANGELVIEW CARE HOMES, INC. @ SAMANTHA
FACILITY NUMBER: 331881044
VISIT DATE: 01/05/2024
NARRATIVE
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and S1 then grabbed R1’s arm and told R1 to go back to R1’s room. Witness interviews were attempted on several occasions but were not successful. Although interview with R1 denied anyone grabbing them in any inappropriate manner, S1’s interview indicated that R1 was having a behavior, and the only way to get R1 back to their room was to forcefully grab R1’s arm to redirect them. Based on interviews with staff, the Department determined that the allegation was 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 discussed with and provided along with copies of the LIC811, LIC9099C, LIC9099D, and Appeal Rights to Administrator May Boco.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20230127150620
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: ANGELVIEW CARE HOMES, INC. @ SAMANTHA
FACILITY NUMBER: 331881044
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2024
Section Cited
CCR
80072(a)(3)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions.. or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training with all staff, and provide proof of such to LPA by POC date.
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Based on staff interview, staff admitted to yanking C1's arm to get C1 to comply. This is an immediate personal rights risk to clients 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/27/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230127150620

FACILITY NAME:ANGELVIEW CARE HOMES, INC. @ SAMANTHAFACILITY NUMBER:
331881044
ADMINISTRATOR:EMBALSADO, MAY BOCOFACILITY TYPE:
735
ADDRESS:23099 SAMANTHA PLACETELEPHONE:
(951) 780-4990
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:4CENSUS: 3DATE:
01/05/2024
UNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Flordeliza Gerarado, CaregiverTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff hit a resident in care.
Staff yelled at resident.
Staff intimidated resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator and informed them of the purpose of this visit. During this investigation, LPA conducted interviews with staff and clients; obtained supportive documentation for review to assist with determining the findings for the above noted allegations. The following was determined.

Allegation #1 – Facility Staff hit a Resident in care. Concerns were expressed that Staff One (S1) hit Resident One (R1). While R1 was at the hospital being treated, R1 was being supervised by S1. Witnesses reported that S1 was seen punching R1. Witness interviews were attempted on several occasions but were not successful. Interview with R1 denied being hit by S1. It should be noted that on the day of LPA’s visit, R1 was
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20230127150620
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: ANGELVIEW CARE HOMES, INC. @ SAMANTHA
FACILITY NUMBER: 331881044
VISIT DATE: 01/05/2024
NARRATIVE
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visibly, and emotionally upset that S1 was not at the facility, as it was S1’s day off. Through interviews with R1, S1, other staff, as well as family, LPA determined that the allegation was Unsubstantiated.

Allegation #2 – Staff yelled at resident. Concerns were expressed that during the same hospital visit, as mentioned above, S1 reportedly yelled at R1 before hitting R1. Interview with R1 denied being yelled at and stated that R1 was their favorite caregiver. Witness interviews were attempted on several occasions but were not successful. Based on interviews with staff, and family, the Department determined that the allegation was Unsubstantiated.

Allegation #3 – Staff intimidated resident. Concerns were expressed that during the same hospital visit, as mentioned above, S1 reportedly, while yelling at R1, was intimidating R1. Witness interviews were attempted on several occasions but were not successful. Interview with R1 denied feeling intimidated. Based on interviews with staff, and family, the Department determined that the allegation was Unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC811 (confidential names list) Administrator May Boco.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5