<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601400
Report Date: 08/05/2022
Date Signed: 08/05/2022 04:02:30 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
08/03/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220803100103
FACILITY NAME:ISLAND ANGEL CARE HOME FOR THE ELDERLYFACILITY NUMBER:
075601400
ADMINISTRATOR:RAMAIYA, MAVISFACILITY TYPE:
740
ADDRESS:5227 STEVEN S. STROUD DRIVETELEPHONE:
(925) 522-8084
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 3DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mavis Ramaiya, Administrator
Gopal Ramaiya, Caregiver(		TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents are not adequately fed
Staff is not able to communicate effectively with residents
Residents are fed expired food
Facility does not provide activities to the residents
Staff falsifies documents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/05/22 at 1PM, Licensing Program Analyst (LPA) conducted an unannounced complaint visit, gathered information on the allegations and delivered the investigation findings to administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Residents are not adequately fed
Investigation Finding: Unsubstantiated
During visit, LPA interviewed R1 who confirmed she is fed 3X per day plus snacks by staff. She stated she loves the food that the staff prepares daily (Mushroom Omelet, Hamburger, Fries, Curry Chicken, Stir Fried vegies, Pancakes, Baked fish, Mixed green salad, etc.). LPA observed sufficient 2 day perishables (Melons, Peaches, Wheat bread, etc.) and 7 day non-perishables in the kitchen and garage refrigerators/freezers and cabinets. LPA also observed R1 and R2 appeared healthy and well fed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
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 15-AS-20220803100103
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: ISLAND ANGEL CARE HOME FOR THE ELDERLY
FACILITY NUMBER: 075601400
VISIT DATE: 08/05/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff is not able to communicate effectively with residents
Investigation Finding: Unsubstantiated
During visit, LPA interviewed staff (S3) in English who stated that she works at the facility every Monday, Wednesday and Friday from 2PM to 5PM. She has worked on call at the facility since September 2020. Her duties include general housekeeping, assisting the 3 residents with showering and grooming as well as doing their laundry. She is bilingual (Spanish and English) and speaks limited English. However, she is able to communicate effectively with residents because one of the residents (R3) speaks Spanish. She stated she also works as a Home Health aide with a Contra Costa County Health agency. LPA observed S3 is able to comprehend English and responds appropriately. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Allegation: Residents are fed expired food
During visit, LPA checked all canned goods in the kitchen and garage cabinets. LPA observed all canned goods were not expired (i.e. Fisha Tuna exp 9/2025; Chef Boyardee Ravioli exp 4/2026; Del Monte Green Beans exp 11/2023; Del Monte Sliced Carrots exp 2/2023; Michigan Made Vegetarian Beans exp 9/2023). LPA interviewed R1 who stated she is not fed expired food. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Allegation: Facility does not provide activities to the residents
Investigation Finding: Unsubstantiated
During visit, LPA observed various activity materials at the facility that residents engage in such as large print word puzzle books, Ring Toss, Checkers, Sit & Throw, Caram Board. Administrator stated residents also prefer to enjoy the nice weather in the back porch where they can sit and relax. Residents also watch TV and do sing-a-longs when they feel like it. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.
Continued on next page, LIC 9099-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
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, 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
08/03/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220803100103

FACILITY NAME:ISLAND ANGEL CARE HOME FOR THE ELDERLYFACILITY NUMBER:
075601400
ADMINISTRATOR:RAMAIYA, MAVISFACILITY TYPE:
740
ADDRESS:5227 STEVEN S. STROUD DRIVETELEPHONE:
(925) 522-8084
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 3DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mavis Ramaiya, Administrator
Gopal Ramaiya, Caregiver(		TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Caregiver working without fingerprint clearance
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/05/22 at 1PM, Licensing Program Analyst (LPA) conducted an unannounced complaint visit, gathered information on the allegations and delivered the investigation findings to administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Caregiver working without fingerprint clearance
Investigation Finding: Unfounded
Based on interviews and record reviews. staff (S3) has been working at the facility on an on call basis since September 2020. While at the facility, LPA reviewed S3's fingerprint clearance documents and association to the facility. This department has investigated the complaint alleging that caregiver working without fingerprint clearance. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

No deficiencies observed during visit. Exit interview conducted and a copy of this report provided via email.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
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 15-AS-20220803100103
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: ISLAND ANGEL CARE HOME FOR THE ELDERLY
FACILITY NUMBER: 075601400
VISIT DATE: 08/05/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff falsifies documents
Investigation Finding: Unsubstantiated
Review of each resident's (R1, R2, & R3) medication administration records from June 2022 to August 2022 show that the prescribed residents' medications were administered and signed by the appropriate staff on duty. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies observed during visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4