079200567-6-4-2025-15-AS-KHOS-DHQQDP-20250617120504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200567
Report Date: 06/04/2025
Date Signed: 06/04/2025 02:18:07 PM

Substantiated

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
05/28/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20250528234401

FACILITY NAME:	ANGEL WINGS CARE HOME III		FACILITY NUMBER:	079200567
ADMINISTRATOR:	YABUT, ANITA		FACILITY TYPE:	740
ADDRESS:	5420 SAN MARTIN WAY		TELEPHONE:	(925) 392-8915
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 5	DATE:	06/04/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Anita Yabut, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff allowed a resident to be soiled while in care
Staff did not meet the needs of a resident while in care

INVESTIGATION FINDINGS:

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On 06/04/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from ADM - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, Needs & Services plan, Home health records and incident reports.

Continued on next page, LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

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 3

Control Number 15-AS-20250528234401

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: ANGEL WINGS CARE HOME III	FACILITY NUMBER: 079200567
	VISIT DATE: 06/04/2025

NARRATIVE

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Allegation: Staff allowed a resident to be soiled while in care
Investigation Finding: Substantiated
During investigation, LPA interviewed reporting party (RP), home health aide (HHA) staff (ADM, S1, S2). Staff (S1, S2, stated they did not find any issue with any resident on 05/22/25 while on duty from 7AM to 7PM. LPA confirmed with HHA that when she arrived on 05/22/25 at 7:30AM to provide care to R1, she found resident lying in bed horizontally with the head of the bed elevated to a sitting position and the foot of the bed also elevated to the highest point, creating a “V” position. HHA stated R1 had a soiled brief and bowel movement, with feces smeared on the bed, bed rails and on R1’s hair. HHA also stated R1 had torn the soiled bed linens to reposition herself or get out of bed. HHA stated she gave R1 a bath and changed her clothes that day. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff allowed a resident to be soiled while in care was found to be substantiated.

Allegation: Staff did not meet the needs of a resident while in care
Investigation Finding: Substantiated
During investigation, LPA interviewed reporting party (RP), home health aide (HHA) staff (S1, S2). HHA confirmed with LPA that when she arrived on 05/22/25 at 7:30AM to provide personal care to R1, she found R1 had a soiled brief and bowel movement, with feces smeared on the bed, bed rails and on her hair. HHA also stated R1 had torn the soiled bed linens to reposition herself or get out of bed. LPA interviewed staff (S1, S2) who stated that they were not aware that R1 had soiled herself in bed on 05/22/25. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not meet the needs of a resident in care was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250528234401

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: ANGEL WINGS CARE HOME III	FACILITY NUMBER: 079200567
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/25/2025 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs…	1 2 3 4 5 6 7	ADM agreed to have additional trained staff provide proper care and supervision to residents in care effective 06/04/25.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff allowed resident to be soiled which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14	By POC due date, ADM also agreed to complete and submit in-service staff retraining on proper care and supervision of residents by an accredited vendor in compliance with Title 22 Section 87468.
Type B 06/25/2025 Section Cited CCR 87411(d)(3)	1 2 3 4 5 6 7	Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.	1 2 3 4 5 6 7	By POC due date, ADM agreed to complete and submit to CCLD in-service staff retraining on proper care and supervision by an accredited vendor in compliance with Title 22 Section 87411
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff did not meet the needs of a resident while in care which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025

LIC9099 (FAS) - (06/04)

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