435294178-2-15-2024-26-AS-KHOS-D36M7L-20240308082142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294178
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:21:47 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220408121347

FACILITY NAME:	ANGELS SENIOR CARE HOME		FACILITY NUMBER:	435294178
ADMINISTRATOR:	LUO, XI-HUA		FACILITY TYPE:	740
ADDRESS:	4078 FREED AVENUE		TELEPHONE:	(408) 244-7689
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	6	CENSUS: 6	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	XI-HUA LUO		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff hits resident.
Staff yells at resident.
Staff handles residents roughly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding and met with administrator (ADM) XI-HUA LUO.

On 04/08/2022, the Department received a complaint with the above allegations.

On 4/14/2022, LPA conducted an initial complaint investigation visit, LPA interviewed ADM, two staff (S1, S2), and 6 residents. Residents' Physician reports, Appraisal Needs and Services Plans of residents, and admission agreement were obtained.

Continued on 9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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 26-AS-20220408121347

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ANGELS SENIOR CARE HOME	FACILITY NUMBER: 435294178
	VISIT DATE: 02/15/2024

NARRATIVE

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Staff hits resident.
Staff yells at resident.
Staff handles residents roughly:

On 4/14/2022, LPA interviewed resident R1. R1 stated no one hit him/her or was rough with him/her, and no one yelled at him/her. R1 stated he/she was not aware of anyone hit or yelled at other residents. LPA interviewed resident R2, R2 denied that any staff hit or yelled at him/her. R2 stated he/she did not see or hear any staff hit or yell at residents. R2 stated staff were not treated him/her roughly. LPA checked resident R1 and R2 with ADM, there were no bruises found on R1's and R2's bodies.

LPA interviewed staff S1. S1 stated he/she did not hit residents, was not rough with residents, did not yell at residents, nor did he/she see or hear staff hit residents, was rough with residents, or yelled at residents. LPA interviewed staff S2. S2 denied that he/she hit the residents, was rough with residents, or yelled at residents. S2 stated he/she did not hear or see any staff hit residents or yell at residents. S2 stated the allegations were not true.

LPA interviewed ADM. ADM stated he/she did not receive any reports regarding that staff hit residents, yelled at residents, or handled residents roughly. ADM stated he/she did not see or hear these allegations. ADM stated he/she interviewed staff, and all staff denied the allegations.

Based on the investigation and interviews, there was no evidence for the allegations.

The Department has investigated the above allegations. Based on interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Exit interview conducted with ADM. This report was provided for signature. A copy of this report was provided to ADM.

Page 2 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2