496804200-8-20-2024-21-AS-BMOS-D8SRQV-20240904131407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804200
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:09:54 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, 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: 4	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Claudia Quijada, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not ensure that resident had clean clothes
Staff are not meeting resident's toileting needs

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 allegations. LPA was greeted by staff Sandra who called Administrator who arrived shortley after. LPA met with Administrator Claudia Quijada.

Staff did not ensure that resident had clean clothes- Complainant alleges resident (R1) is always wearing the same clothing and is not being showered. LPA conducted visits of facility on 6/7/2024 & 6/11/2024 and observed R1 to be dressed, clean shaven, without any odor, as well room was clean with many clean shirts hanging in the closet and clothes in dresser. LPA’s interview with R1 advised they do not need help showering or changing cloths. R1’s Physician’s report obtained dated 10/3/2022 revealed R1 is ambulatory and able to bathe self (with encouragement) and dress self. Interview with Administrator indicated R1 likes the same clothes and has many of the same style of clothing. R1 is private/shy and bathes reluctantly 1 to 2 times a week with assistance by caregiver who will be in the shower but without facing R1 directly.
Continue on LIC9099-C

Unsubstantiated

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: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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 4

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: 08/20/2024

NARRATIVE

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Continue from LIC9099

Although R1 likes to wear the same type of clothing and is reluctant to shower, LPA’s record review, observations, & interviews conducted, allegation Staff did not ensure that resident had clean clothe is found to be Unsubstantiated.

Staff are not meeting resident's toileting needs- Complainant alleges R2 is left with feces on private parts due to day staff not cleaning R2 properly. LPA contacted outside medical vendor who informed for the past three years of caring for R2 every other week, they have not observed R2 have feces on them or dirtied undergarments from incontinent issues. LPA spoke with an additional outside medical vendor who has seen R2 twice a week for the last two years and corroborated first medical vendors’ statement. LPA conducted visits of facility, reviewed records, and conducted interviews that did not indicate allegation Staff are not meeting resident’s toileting needs, therefore the allegation is Unsubstantiated.

A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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, 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: 4	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Claudia Quijada, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Residents did not receive medications as prescribed

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.

Resident did not receive medications as prescribed- Complainant alleges prior to licensure, there were residents in the home and a resident/individual (I1) was not receiving their medications as prescribed. The Department issued a Change of Ownership (CHOW) for this facility address on 5/22/2024. Facility records and LPA’s interview with Administrator revealed the facility was under a different license number and name prior to CHOW when I1 was living at facility. I1 moved out prior to new license. During LPA’s record review of facility from pre-licensing inspection dated 5/14/2024, I1 was not indicated as being a resident. Records obtained from facility for past resident (I1) all have previous license name & number and medication records show last medications given I1 was 5/12/2024. Although during LPA’s 6/7/2024 visit of facility, LPA observed medication closet unlocked.
Continue on LI9099-C

Unfounded

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: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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 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: 08/20/2024

NARRATIVE

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Continue from LIC9099-A

In the med closet were pre poured medications for all residents (see pics) including previous residents who left prior to CHOW. In the medication closet is a refrigerator for medications needing refrigeration. LPA observed it to be full of insulin for I1 (see pics). LPA will address on case management. Based on LPAs interviews with staff, complainant, and documents obtained indicating individual was not a resident under this license name or number, therefore allegation Resident did not receive medications as prescribed is Unfounded.

A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4