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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345003013
Report Date: 10/28/2025
Date Signed: 10/28/2025 10:13:10 AM

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
02/07/2025 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20250207161111
FACILITY NAME:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR:BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT DRTELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver Edghard ZadrachTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining a fracture due to a fall.
Staff neglect resulted in a resident sustaining multiple pressure injuries.
Staff neglect led to the serious hospitalization of a resident.
Facility did not notify responsible parties of hospitalization.
INVESTIGATION FINDINGS:
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On 10/28/2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Graham Gunby arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Caregiver Edghard Zadrach.

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

The results of the investigation are as follows:

**Report continued on 9099-C**
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Lavinia Muscan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
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 5
Control Number 59-AS-20250207161111
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: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
VISIT DATE: 10/28/2025
NARRATIVE
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Staff neglect resulted in a resident sustaining a fracture due to a fall.
On October 20, 2024, R1 sustained a fall at the facility while attempting to stand from a reclining chair and reach for a walker without staff assistance. As a result of the fall, R1 suffered a displaced fracture of the right femoral neck, as confirmed by medical records. Based on R1’s physician's report (LIC602), R1 required assistance with transferring and bed mobility. Additionally, R1’s family had previously informed the facility that R1 required assistance with all transfers and needed supervision when ambulating due to a known fall risk. The department attempted to obtain R1’s assessment and needs and service plan from the facility however the licensee indicated the facility did not have requested documentation. R1 was admitted to skilled nursing for rehabilitation and returned to the facility on 11/15/2024. Based on the investigation, the facility did not implement appropriate supervision or safety interventions despite having prior knowledge of R1’s fall risk in addition to the absence of updated needs and service plan. Based on the information gathered, above allegation is SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Staff neglect resulted in a resident sustaining multiple pressure injuries.
On February 5, 2025, a Home Health nurse notes report a new wound was observed on R1’s coccyx. The wound measured 5 x 4 x 0.3 cm and was documented as a suspected deep tissue injury. Medical records indicate staff were unable to report when the wound had developed. As a result, wound care orders were initiated. The investigation determined that the facility did not consistently implement pressure injury prevention and wound care measures as directed by home health nurse. This failure resulted in R1 developing a Stage 4 pressure injury to the coccyx, as well as a worsening pressure injury to the right heel. Based on the investigation, the department substantiates the finding that staff neglect resulted in R1 sustaining multiple pressure injuries. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Continue on 9099-C ...
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Lavinia Muscan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250207161111
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: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
VISIT DATE: 10/28/2025
NARRATIVE
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PAGE 2 CONTINUED FROM 9099-C ...

Staff neglect led to the serious hospitalization of a resident.
Based on review of medical records, staff interviews, and facility documentation, the Department substantiated that neglect by facility staff contributed to R1’s hospitalization on February 5, 2025, due to a severe coccyx pressure ulcer and suspected dehydration leading to acute kidney injury. The facility failed to assess their capacity and capability to care for R1, even with home health support. The facility failed to coordinate with home health care for R1's needs to address R1's pressure injury, and transfer R1 to a higher level of care. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Facility did not notify responsible parties of hospitalization.
Based on records reviewed, the records revealed on February 5, 2025, R1 was transported to the hospital via 911 due to a severe coccyx pressure injury. The investigation determined that the facility did not notify the responsible party, or any family members, of the hospitalization. Family members were informed by the hospital that R1 was admitted to the hospital. Based on the information gathered, above allegations are SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted, deficiencies cited on LIC809D per Title 22, and appeal rights were given. A civil penalty in the amount of $500 is assessed. The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Lavinia Muscan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20250207161111
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: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2025
Section Cited
CCR
87466
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Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not evidenced by:
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Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 10/29/2025.
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Based on record review and interviews, the licensee did not comply with this section as R1 was not regularly observed for changes. This poses an immediate Health and Safety risk to resident in care.
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$500 Civil Penalty
Type A
10/29/2025
Section Cited
CCR
87463(f)
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Reappraisals (f)The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record. This requirement is not evidenced by:
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Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 10/29/2025.
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Based on interviews and record review, the licensee failed to notify R1’s responsible party when R1 was admitted to the hospital. This poses an immediate Health and Safety risk to resident 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.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Lavinia Muscan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20250207161111
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: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not evidenced by:
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Licensee shall send a letter of understanding of this regulation and shall conduct staff training. All POC documents are due by 10/29/2025.
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Based on interviews and record review, the licensee failed to provide care and supervision which resulted in R1’s fall leading to a fracture. This poses an immediate Health and Safety risk to resident 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.
NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Lavinia Muscan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
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