565801215-8-1-2022-29-AS-JAPL-CHDMN2-20220817094445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801215
Report Date: 08/01/2022
Date Signed: 08/01/2022 11:35:40 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
07/22/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220722153110

FACILITY NAME:	ANGELS II		FACILITY NUMBER:	565801215
ADMINISTRATOR:	JOANN TRUPIANO		FACILITY TYPE:	740
ADDRESS:	2375 MCDONALD COURT		TELEPHONE:	(805) 404-5201
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 5	DATE:	08/01/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Honoratapa Avestro		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Facility is dirty

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced initial 10-day complaint visit to this facility. The LPA met with staff and explained the reason for the visit. The LPA spoke to Administrator Joann Trupiano over the phone and authorized staff Honor to sign the report.

During today’s visit, the LPA conducted a physical plant tour at 9:50 a.m.

Regarding the allegation: Facility is dirty
It was alleged that on 7/19/2022, a credible witness came into the facility and observed that the house looked dirty. During today’s visit, upon arrival the LPA observed that the carpet had appeared stained with dark spots leading from the garage door toward the dining room. At 9:50 a.m. the LPA observed the dining room and saw dark stains leading from the patio sliding door toward the living room. Resident room #4 appeared to have dark stains on the carpet upon entering.
Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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 29-AS-20220722153110

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: ANGELS II	FACILITY NUMBER: 565801215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/08/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 (a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Clean and disinfect refrigerator and frezzer and provide proof to CCL no later than 8/8/22. 2. Deep clean carpets and remove stains and provide proof to CCL no later than 8/8/22.
	8 9 10 11 12 13 14	Based on Observation, the licensee did not comply with the section cited above, as the facility did not maintain clean carpets, refrigerator and freezer which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	3. Declutter the garage and provide proof to CCL no later than 8/8/22.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220722153110

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: ANGELS II	FACILITY NUMBER: 565801215
	VISIT DATE: 08/01/2022

NARRATIVE

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At 9:54 a.m. the LPA observed the garage to be cluttered with limited walking space available. The LPA observed the freezer in the garage at 9;55 a.m. which had what appeared dried liquids that had not been cleaned after a spill. At 9:56 a.m. the LPA observed the kitchen refrigerator which also appeared to have dried liquids and stains from a spill that was not cleaned. The LPA’s observations supported claims from a credible witness that the facility is dirty and raising concerns that cleaning protocols are not being met. The LPA discussed appropriate cleaning protocols with Staff Honoratapa Avestro. Based on the investigation, there is sufficient evidence to support the claim that the facility is dirty. This allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC9099 (FAS) - (06/04)

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