075601522-6-13-2024-15-AS-YFLS-D7GS9E-20240724134035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601522
Report Date: 06/13/2024
Date Signed: 06/13/2024 02:59:44 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2024 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240603164253

FACILITY NAME:	ANGELS CARE HOME		FACILITY NUMBER:	075601522
ADMINISTRATOR:	BANGI, ANGELINE S		FACILITY TYPE:	740
ADDRESS:	1511 BUENA VISTA STREET		TELEPHONE:	(925) 219-2250
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	06/13/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Liezyl Ajos		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident left unattended in bathroom

INVESTIGATION FINDINGS:

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On this day at around 10:10 am, LPAs Luisa Fontanilla and Tonica Syess-Gibson arrived unannounced to conduct investigation on the above allegation. LPAs met with Liezyl Ajos. LPAs explained to Ajos the purpose of the visit.

During the course of investigation, LPAs reviewed records and interviewed Resident 1 (R1) and two staff(S1 and S3). LPAs reviewed R1's 2023 Physician's Report and Service Plan. Based on record review conducted, R1 has Dementia and needs assistance with activities of daily living (ADLs). On 5/31/2024, S1 states R1 was assisted by S2 to the bathroom then waited outside the bathroom with the door ajar. S3 then came to switch with S2 to assist R1 as R1's preference is a female staff. S3 noticed the door was locked and could not open the door. S3 asked assistance from other staff to get the door opened.

continuation on Lic 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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 15-AS-20240603164253

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ANGELS CARE HOME	FACILITY NUMBER: 075601522
	VISIT DATE: 06/13/2024

NARRATIVE

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S1 and a hospice nurse who was at the facility responded and were able to open the door. LPAs interviewed the nurse who states that R1 was inside the bathroom for approximately 5 minutes. The nurse states R1 was observed smiling and sitting on the toilet when the door was opened.

Staff interviewed denied leaving R1 in the bathroom unattended. Staff stated the door was accidentally locked by one of the residents but has been replaced by new hardware that doesn't require a key when locked.

LPAs interviewed R1 who states that R1 likes and feels safe living at the facility. R1 states R1 likes the staff. However, R1 states that R1 prefers a female caregiver. R1 does not recall the incident that happened on May 31, 2024 when R1 got locked in the bathroom. Based on interviews and record reviews conducted, the above allegation is unsubstantiated.

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.

No deficiencies during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC9099 (FAS) - (06/04)

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