496804200-6-11-2024-21-AS-BMOS-D8SRQW-20240904131407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804200
Report Date: 06/11/2024
Date Signed: 06/11/2024 12:49:07 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240606100350

FACILITY NAME:	ANGELS ASSISTED LIVING LLC		FACILITY NUMBER:	496804200
ADMINISTRATOR:	QUIJADA, CLAUDIA		FACILITY TYPE:	740
ADDRESS:	5525 CARRIAGE LANE		TELEPHONE:	(707) 791-3172
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	5	CENSUS: 3	DATE:	06/11/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Claudia Quijada, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Uncleared adult residing in facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Hansen arrived unannounced, for the purpose of delivering findings of complaint investigation, regarding the above listed allegation. LPA met with Administrator Claudia Quijada.

Uncleared adult residing in facility- Complainant alleges there are individuals renting a room in the facility that is not cleared. Investigation revealed, the Administrator rented a room to an individual but had not associated them to this facility. LPA interview with Administrator, Individual (I1) has been renting a staff room in the facility but did not associate I1 to facility. On 6/7/2024 when LPA conducted 10 day and opened complaint, LPA was met by only staff (S1) at facility. When Administrator arrived and provided list of all facility staff, it was revealed not only was S1 but also S2 had been working at the facility between (2) two and (4) four months without being background checked /cleared to work, reside, or volunteer at a facility.

Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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 21-AS-20240606100350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ANGELS ASSISTED LIVING LLC	FACILITY NUMBER: 496804200
	VISIT DATE: 06/11/2024

NARRATIVE

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Allegation, Uncleared adult residing in facility, is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

A $500.00 civil penalty was assessed on today’s date for not having a clearance transfer for I1.

A $1,000.00 civil penalty was assessed on today’s date for uncleared adult S1 & S2.

Total civil penalties today $1,500.00

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240606100350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ANGELS ASSISTED LIVING LLC	FACILITY NUMBER: 496804200
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/12/2024 Section Cited CCR 87355(e)(2)	1 2 3 4 5 6 7	Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administration was given by end of 6/7/2024 to associate I1 to the facility as required by Title 22 regulations for CP’s to be $100, if not they would be $500. I1 was associated 6/10/2024. POC has been cleared at visit.
	8 9 10 11 12 13 14	Based upon statements and record review, I1 who is not associated to the facility and has been residing at facility for over 2 months. This poses an immediate risk to the safety and personal rights of the residents in care.	8 9 10 11 12 13 14	***Civil Penalties assessed at $500.
Type A 06/12/2024 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	87355(e)(1)Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to Health & Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met, As evidenced by:	1 2 3 4 5 6 7	Facility to submit a written plan that they understand regulation and how it will maintain compliance. Interview with Administrator and Background clearance/association revealed S1 is still in process and will not be in the facility until cleared and associated. S2 has been cleared and associated to facility.
	8 9 10 11 12 13 14	Based on interview with administrator, & S1, along with records reviewed it was revealed staff S1 & S2 did not have the proper fingerprint clearance & had access to residents in care for over 2 months. This is an immediate risk to the Health & safety of residents in care.	8 9 10 11 12 13 14	*** Civil Penalties assessed at $1,000.00

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC9099 (FAS) - (06/04)

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