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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200567
Report Date: 03/17/2026
Date Signed: 03/17/2026 04:27:58 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
03/11/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260311144822
FACILITY NAME:ANGEL WINGS CARE HOME IIIFACILITY NUMBER:
079200567
ADMINISTRATOR:YABUT, ANITAFACILITY TYPE:
740
ADDRESS:5420 SAN MARTIN WAYTELEPHONE:
(925) 392-8915
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
03/17/2026
UNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Anita Yabut, Administrator
Marlyn Joaquin, Caregiver		TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff failed to respect resident's privacy while in care
INVESTIGATION FINDINGS:
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On 03/17/26 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (S1, S2) and spoke with administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA gathered information and delivered investigation findings of above allegations to staff (ADM, S1, S2). LPA explained the purpose of the visit with staff (ADM, S1, S2).

During investigation, LPA interviewed reporting party (RP), responsible party (DPOA), staff (S1, S2) and obtained the following documents from ADM - staff roster, residents’ roster, R1’s admission agreement, physicians report, ID/Emergency information, Needs & Services plan, After discharge summary report 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: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
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 15-AS-20260311144822
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: 03/17/2026
NARRATIVE
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Allegation: Staff failed to respect resident’s privacy while in care
Investigation Finding: Substantiated
During investigation, LPA interviewed reporting party (RP), responsible party (DPOA), and staff (ADM, S1, S2). DPOA stated that on 11/06/25, resident (R1) was in her bedroom conversing via speaker phone with her. In the middle of their telephone conversation, staff (S1) physically went inside R1’s bedroom after eavesdropping on R1 and started interjecting in DPOA and R1’s telephone conversation, explaining why staff failed to provide timely service to R1. Review of audio recording dated 11/06/25 confirmed that staff failed to respect resident’s privacy while in care. 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 failed to respect resident’s privacy while in care was found to be substantiated.

Deficiency is 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 a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
03/11/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260311144822

FACILITY NAME:ANGEL WINGS CARE HOME IIIFACILITY NUMBER:
079200567
ADMINISTRATOR:YABUT, ANITAFACILITY TYPE:
740
ADDRESS:5420 SAN MARTIN WAYTELEPHONE:
(925) 392-8915
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
03/17/2026
UNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Anita Yabut, Administrator
Marlyn Joaquin, Caregiver		TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff verbally abuse resident in care
INVESTIGATION FINDINGS:
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On 03/17/26 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (S1, S2) and spoke with administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA gathered information and delivered investigation findings of above allegations to staff (ADM, S1, S2). LPA explained the purpose of the visit with staff (ADM, S1, S2).

During investigation, LPA interviewed reporting party (RP), responsible party (DPOA), staff (S1, S2) and obtained the following documents from ADM - staff roster, residents’ roster, R1’s admission agreement, physicians report, ID/Emergency information, Needs & Services plan, After discharge summary report and incident reports.

Continued on next page, LIC 9099-C pg1
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
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 5
Control Number 15-AS-20260311144822
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: 03/17/2026
NARRATIVE
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Allegation: Staff verbally abuse resident in care
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed reporting party (RP), responsible party (DPOA), and staff (ADM, S1, S2). DPOA reported that staff (S1, S2) accused R1 of complaining to her family constantly about the food they prepare for her, that they even spend their own money to buy food for her, that the amount of money R1 pays for her stay at the facility is nothing because of the high cost of food and that she is a “ big problem for them”. DPOA stated staff commented to R1 on 03/02/26 that “We are not being paid enough to care for you. You constantly complain to your family that the food we serve you is no good.” DPOA stated that staff raised their voices at R1 even though she was wearing her hearing aids and could clearly hear them. DPOA stated that after R1’s encounter with S1 and S2 on 03/02/26, R1 stayed in her room feeling belittled, hurt and depressed. ADM talked with R1 about the incident the same day and followed up with S1/S2 who denied verbally abusing R1. S1, S2 stated that sometimes R1 does not wear her hearing aids which would require them to increase the volume of their voices so that she could hear them. Staff denied yelling at R1. LPA also interviewed other staff (S3) and residents (R2, R3) who did not witness staff yell or verbally abuse R1. 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 that staff verbally abuse resident in care is unsubstantiated.

Exit interview conducted and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20260311144822
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: 03/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2026
Section Cited
CCR
87468.2(a)(1)
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In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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By POC due date, administrator agreed to complete and submit in-service staff training by an accredited CCL vendor on residents’ personal rights in compliance with Title 22 Section 87468.2 (a)(1)
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This requirement was not met as evidenced by staff failing to respect resident’s private telephone conversation which posed a potential health & safety risk to residents 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5