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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801598
Report Date: 12/22/2021
Date Signed: 12/22/2021 02:15:14 PM



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
10/06/2021 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211006155454
FACILITY NAME:ANGELS IIIFACILITY NUMBER:
565801598
ADMINISTRATOR:JOANN TRUPIANOFACILITY TYPE:
740
ADDRESS:3216 YARDLEY PLACETELEPHONE:
(805) 581-9422
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:0CENSUS: 0DATE:
12/22/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Joann TrupianoTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff did not safeguard resident's personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent telephonic complaint visit to deliver the findings for the above allegation, as the facility was closed effective 11/02/2021. The complaint was initiated by LPA on 10/06/2021. LPA spoke with Administrator, Joann Trupiano and the reason for the call was explained. Entrance interview conducted.

It was alleged that facility staff did not safeguard resident’s personal property. It was reported that the facility discarded all of Resident #1 (R1s) belongings two (2) weeks prior to R1s passing. The missing items include but are not limited to a ring, a walker, and a hospital bed. During the initial 10-day visit, LPA Guzman Chavez conducted a tour of the physical plant, interviewed the Administrator, and obtained copies of pertinent documentation.

Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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 5
Control Number 29-AS-20211006155454
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 III
FACILITY NUMBER: 565801598
VISIT DATE: 12/22/2021
NARRATIVE
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Continued from LIC 9099...

Information gathered during the course of the investigation revealed that upon arrival to the facility, Resident #1 (R1) had a ring, a walker, and later on a hospital bed which was purchased by R1’s spouse and delivered to the facility on 11/22/2016 and signed off by staff. Interviews with former staff revealed that all clothes and belonging that were of R1 were placed in bags for R1s family member to pick up. It was further revealed that a few pieces of clothing that were ripped or old were thrown away. Interview with the Administrator revealed that she attempted to communicate with R1s spouse about the walker and hospital bed, both which were old and broken; however, items were thrown away as the administrator did not receive any communication back. Further review of documents reflected that even though it was alleged that R1s ring was not returned, a family member signed off that it was received on 09/28/2021 along with a refund of last 4 days. Based on all information gathered, the administrator discarded R1s walker, hospital bed and some clothing items. Therefore, based on the interviews, the allegation of “facility staff did not safeguard resident’s personal property” is deemed Substantiated at this time.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D).

Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of report provided via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20211006155454
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 III
FACILITY NUMBER: 565801598
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2021
Section Cited
CCR
87217(b)
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87217(b) Safeguards for Resident Cash, Personal Property, and Valuables: Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff…

This requirement is not met as evidenced by:
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Facility closed effective November 2, 2021.
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Based on interviews, the licensee did not comply with the section cited above as they discarded R1’s clothes, hospital bed and walker which poses a potential personal rights risk to persons in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/06/2021 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211006155454

FACILITY NAME:ANGELS IIIFACILITY NUMBER:
565801598
ADMINISTRATOR:JOANN TRUPIANOFACILITY TYPE:
740
ADDRESS:3216 YARDLEY PLACETELEPHONE:
(805) 581-9422
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:0CENSUS: 0DATE:
12/22/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Joann TrupianoTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility has rodents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent telephonic complaint visit to deliver the findings for the above allegations, as the facility was closed effective 11/02/2021. The complaint was initiated by LPA on 10/06/2021. LPA spoke with Administrator, Joann Trupiano and the reason for the call was explained. Entrance interview conducted.

It was alleged that facility has rodents. During the course of the investigation, LPA conducted interviews with former Angels III staff on 11/04/2021 between 2:00 p.m. and 2:42 p.m. Additionally, LPA conducted an interview with a former resident family member on 11/08/2021 at 1:27 p.m., and former resident on 12/01/2021 at 2:05 p.m.

Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20211006155454
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 III
FACILITY NUMBER: 565801598
VISIT DATE: 12/22/2021
NARRATIVE
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Continued from LIC 9099...

Interview with former resident revealed that they did not see any rodents or droppings while residing at the facility. Additionally, interview with former resident’s family member revealed that the facility was clean both before and after their family member had moved into the facility. Furthermore, family member stated, facility was clean and organized and if there were any pests or rodents present at any time, former resident would have mentioned it to them. Interviews with former staff further revealed that they had seen rodent droppings outside of the facility only. Interview with the Administrator revealed that due to the house being on the mountain, many animals would come down looking for food. Administrator also reported that a pest control company had come to the facility on 10/10/2021 to service Rodent Proofing as she plans to move into the home. Based on the interviews, there is insufficient evidence to prove there was rodents inside the home. Therefore, the allegation of “facility has rodents” is deemed Unsubstantiated this time.

Exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5