405850256-12-15-2022-29-AS-KBUY-CMLM9K-20221230082450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850256
Report Date: 12/15/2022
Date Signed: 12/15/2022 07:04:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20220628090126

FACILITY NAME:	ANGEL'S GROUP HOME LLC		FACILITY NUMBER:	405850256
ADMINISTRATOR:	WON, YOUNG		FACILITY TYPE:	735
ADDRESS:	621 PALOMINO CIRCLE		TELEPHONE:	(805) 610-3676
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	4	CENSUS: 4	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Junsik Kim / Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff yells at a client while in care.

Staff inappropriately grabbed a client while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 8:00am on 12/15/2022, Licensing Program Analyst (LPA) Jeffries arrived unannonced at the facility to issue final findings to the allegations of this complaint. LPA met with Junsik Kim and announced who he was and the reason for the visit.
As to the allegation of, “Staff yells at a client while in care.” It was discovered through interviews, and observations that on 06/19/2022, C1 was on a group outing at a local park with the facility clients and staff. C1 was interviewed on 06/28/2022, 07/07/2022, 10/13/2022, where C1 indicated that they were upset at S1 and didn’t like that S1 told them “No” in a subject that C1 did not remember. C1 demonstrate to LPA and Quality Assurance Coordinator from Tri Counties Regional Center their interpretation of how S1 yelled “No” to C1, C1 stated, “she told me ‘no’ and I didn’t feel good.” LPA asked C1 if S1 yelled “No” and C1 one stated, “[they] told me no.” Interviews with S1 on 06/28/2022, S1 stated that they didn’t recall the specific event in question but did recall helping C1 with helping to putt C1’s jacket on. S1
CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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 2

Control Number 29-AS-20220628090126

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGEL'S GROUP HOME LLC	FACILITY NUMBER: 405850256
	VISIT DATE: 12/15/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

denied yelling at C1. Interviews with C2 on 06/28/2022, and C3, and C4 on 10/13/2022 did not recall S1 yelling at any of the clients and did not see S1 grab any of the clients. At this time there is not enough evidence to support the allegation of, “Staff yelled at client while in care.” and is unsubstantiated at this time.
As to the allegation of, “Staff inappropriately grabbed a client while in care.” It was discovered through interviews, and observations that on 06/19/2022, C1 was on a group outing at a local park with the facility clients and staff. C1 was interviewed on 06/28/2022, 07/07/2022, 10/13/2022, where C1 indicated that they were upset at S1 and didn’t like that S1 told them “No” in a subject that C1 did not remember. C1 demonstrate to LPA and Quality Assurance Coordinator from Tri Counties Regional Center their interpretation of how S1 yelled “No” to C1, C1 stated, “she told me ‘no’ and I didn’t feel good.” LPA asked C1 if S1 yelled “No” and C1 one stated, “[they] told me no.” C1 stated that S1 grabbed C1’s arm when S1 put their jacket on and it hurt, according to C1. LPA observed a photo of C1’s arm taken 06/22/2022 and did not view any marks or bruising. Interviews with S1 on 06/28/2022, S1 stated that they didn’t recall the specific event in question but did recall helping C1 with helping to putt C1’s jacket on, S1 denied miss handling C1 while help putting C1’s jacket on. Interviews with C2 on 06/28/2022, and C3, and C4 on 10/13/2022 indicated that they did not recall S1 yelling at any of the clients and did not see S1 grab any of the clients. At this time there is not enough evidence to support the allegation of, “Staff inappropriately grabbed a client while in care.” and is unsubstantiated at this time.

No citations issues. Exit interview, reprot signed, and report emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2