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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530240
Report Date: 04/29/2026
Date Signed: 04/29/2026 05:16:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
04/22/2026 and conducted by Evaluator Andrew Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260422110040
FACILITY NAME:ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLCFACILITY NUMBER:
335530240
ADMINISTRATOR:MAZARIEGOS, JOHNNYFACILITY TYPE:
740
ADDRESS:36785 BRAKEN WAYTELEPHONE:
(951) 452-1216
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY:6CENSUS: 6DATE:
04/29/2026
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Caregiver, Guilbert OteyzaTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Staff lock residents inside the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Andrew Martinez made an unannounced visit to the facility to
initiate a complaint investigation and deliver findings for the above allegation. LPA met with Caregiver, Gilbert Oteyza, and explained the purpose for today's visit. The investigation consisted of observations, record reviews, and interviews with pertinent parties.
Regarding the allegation - Staff lock residents inside the facility: During facility tour, LPA observed a child-proof door lever latch lock located on the inside of the entryway (front) door. LPA interviewed two (2) staff caregivers (S1, S2), both of whom stated the lever latch lock was installed to safeguard Resident 1 (R1) from eloping again as they like to open doors and have prior elopement history. LPA observed the front door is equipped with a signal system to notify staff when door has been opened.
Based on today's investigation, the above allegation is SUBSTANTIATED. A SUBSTANTIATED finding is defined as a violation has occurred based on the preponderance of available evidence. An exit interview was conducted where this report LIC9099, LIC9099D and Appeal Rights were discussed and a copy provided to Caregiver, Gilbert Oteyza.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Andrew Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
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 56-AS-20260422110040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLC
FACILITY NUMBER: 335530240
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2026
Section Cited
CCR
87705(e)(4)
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(e) Licensees that use delayed egress devices on exterior doors... shall meet the following... requirements: (4) Residents who... indicate a desire to leave the facility following redirection shall be permitted... with staff supervision. The facility did not meet this requirement as evidenced by:
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Licensee shall remove the child-proof door lever latch lock from the inside of the front door within 24 hours. Licensee shall submit photographic proof of the removal of latch lock, review the stated regulation, and submit a statement of understanding of regulation reviewed to LPA via email by POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section sited above by installing a child-proof door lever latch lock on the entryway (front) door making it inaccessible to residents in care wich poses an immediate health, safety or personal rights risks to persons 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: Karen Clemons
LICENSING EVALUATOR NAME: Andrew Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
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