342700554-12-13-2023-59-AS-APEZ-CYYPRD-20231229103235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700554
Report Date: 12/13/2023
Date Signed: 12/13/2023 12:15:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2023 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20231204141005

FACILITY NAME:	ANGIES CARE HOME		FACILITY NUMBER:	342700554
ADMINISTRATOR:	CRUDO, ANGELINA		FACILITY TYPE:	740
ADDRESS:	8558 SHERATON DR		TELEPHONE:	(916) 962-2460
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 5	DATE:	12/13/2023
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Angelina Crudo, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not notify resident's authorized representative of resident's hospitalization in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Angelina Crudo, to deliver findings into the complaint allegation listed above.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff did not notify resident's authorized representative of resident's hospitalization in a timely manner

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

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 59-AS-20231204141005

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGIES CARE HOME	FACILITY NUMBER: 342700554
	VISIT DATE: 12/13/2023

NARRATIVE

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Relevant party reported that facility sent a resident (R1) to the hospital without notifying R1's authorized representative of the hospitalization in a timely manner.

During the investigation, LPA requested a written Unusual Incident Report (SIR) regarding R1's hospitalization from Administrator. LPA received an SIR regarding R1's hospitalization that was authored by Administrator on 12/7/2023 reporting that R1 was sent to the hospital on 11/24/2023.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20231204141005

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGIES CARE HOME	FACILITY NUMBER: 342700554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/31/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 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. This requirement was is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will complete a statement of understanding regarding regulation 87211 and submit statement to LPA by POC due date of 12/31/2023.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, facility didn't ensure R1's hospitalization was reported in a timely manner, which poses a potential health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC9099 (FAS) - (06/04)

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