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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850404
Report Date: 02/13/2024
Date Signed: 02/15/2024 09:25:38 AM

Substantiated


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
09/26/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20230926101727
FACILITY NAME:ANGEL'S GROUP HOMEFACILITY NUMBER:
405850404
ADMINISTRATOR:KIM, JUNSIKFACILITY TYPE:
735
ADDRESS:189 RIVERBANK LANETELEPHONE:
(805) 610-3676
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:4CENSUS: 4DATE:
02/13/2024
UNANNOUNCEDTIME BEGAN:
07:43 AM
MET WITH:Administrator - Young WonTIME COMPLETED:
09:44 AM
ALLEGATION(S):
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Facility staff did not seek medical attention for resident in a timely manner.
Staff left resident on floor for an extended period of time.
INVESTIGATION FINDINGS:
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 At 8:00am on 02/15/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to deliver final findings to the allegations above to this complaint. LPA met with Young Won, announced who he is and the reason for the visit.

As to the allegations of, "Facility staff did not seek medical attention for resident in a timely manner." and
"Staff left resident on floor for an extended period of time." It was discovered through investigation, interviews and documentation that on 09/24/2023, at approximately 1700 hours, Client 1 (C1) sustained a fall at the entrance of the facility. Staff 1 (S1) prompted C1 to get up by providing her a chair for leverage, but C1 was unable to. S1 called Licensee Young Won, who arrived at the facility shortly after. C1 complained of pain, and was given pain medication. After several hours, it was decided that C1 would spend the night on a floor mattress.
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
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)
Page: 1 of 4
Control Number 29-AS-20230926101727
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
FACILITY NUMBER: 405850404
VISIT DATE: 02/13/2024
NARRATIVE
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 The following day C1 was still not able to get up and continued to complain of shoulder pain. S2 called the Administrator, and the Administrator instructed S2 to call 911. At 0949 hours, a call was made requesting emergency medical services. C1 was transported to the hospital and diagnosed with a right broken humerus. Per the hospital notes: “It is important that we prevent future falls for C1, as C1's Xarelto medication makes C1 higher risk to have major bleeding including bleeding inside of C1's brain which could result in permanent brain damage or even death.” Additionally, C1 was left on the floor after the fall for an extended period of time, before calling Administrator to drive to the facility and then help C1 off the floor. At this time there is enough evidence to support the allegations of, "Facility staff did not seek medical attention for resident in a timely manner." and "Staff left resident on floor for an extended period of time." and both are substantiated at this time.

Exit interview, report read, citation issued, appeal rights and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
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 4
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
09/26/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20230926101727

FACILITY NAME:ANGEL'S GROUP HOMEFACILITY NUMBER:
405850404
ADMINISTRATOR:KIM, JUNSIKFACILITY TYPE:
735
ADDRESS:189 RIVERBANK LANETELEPHONE:
(805) 610-3676
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:4CENSUS: 4DATE:
02/13/2024
UNANNOUNCEDTIME BEGAN:
07:43 AM
MET WITH:Administrator - Young WonTIME COMPLETED:
09:44 AM
ALLEGATION(S):
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2
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Staff did not adequately supervise resident in care resulting in resident sustaining a fractured arm.
INVESTIGATION FINDINGS:
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 At 8:00am on 02/15/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to deliver final findings to the allegations above to this complaint. LPA met with Young Won, announced who he is and the reason for the visit.
As to the allegation of, "Staff did not adequately supervise resident in care resulting in resident sustaining a fractured arm." It was discovered through interviews, and documentation that on 09/24/2023, at approximately 1700 hours, Cleint 1 (C1) and three other Clients (C2, C3, and C4) arrived at the facility from an outing. Staff 1 (S1) was assisting the residents off the bus, when C1 walked inside the facility and tripped at the entrance door sustaining a fractured arm. C1 can ambulate without assistance; therefore, staff did not neglect C1. There is not enough evidence to support the allegation of, "Staff did not adequately supervise resident in care resulting in resident sustaining a fractured arm." and is unsubstantiated at this time.

Exit interview, report read, and report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
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)
Page: 3 of 4
Control Number 29-AS-20230926101727
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
FACILITY NUMBER: 405850404
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
85075(b)
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85075 Health related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not met by evidence of C1 having
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Adminstor agrees to have all staff at this facility condut one hour training on genreal 1st aide. Adminstrator will provide trainer and schdule with list of staff being trained by 02/16/2024 to LPA via email (mark.jeffries@dss.ca.gov)
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to wait overnight for basic medical services and puts clients in immediate danger.
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Type A
02/16/2024
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement
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Adminstor agrees to have all staff at this facility condut one hour training on when to call 911. Adminstrator will provide trainer and schdule with list of staff being trained by 02/16/2024 to LPA via email (mark.jeffries@dss.ca.gov)
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was not met by evidence of C1 having broken humerus and not being transported to emergency services in a timely manor which puts clients in immediate danger.
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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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4