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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200741
Report Date: 06/30/2023
Date Signed: 06/30/2023 04:42:21 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
06/28/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20230628124500
FACILITY NAME:ANGEL'S LOVE RCFEFACILITY NUMBER:
079200741
ADMINISTRATOR:BADEO, MARCELINA M.FACILITY TYPE:
740
ADDRESS:281 PUEBLO DRIVETELEPHONE:
(925) 876-0605
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 6DATE:
06/30/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jose Camus, Direct Support ProfessionalTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Resident sustained black eye while under care.

Resident AWOL'ed while under care.
INVESTIGATION FINDINGS:
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On 6/30/2023 at 2:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegations above. LPA met with Rhonette Santos, Co-Administrator. LPA spoke with Administrator, Marcelina Badeo via telephone and explained the reason for the visit.

During the course of the investigation LPA interviewed Staff, Reporting Party (RP), and a Resident 1 (R1). LPA requested the following documents for R1 be emailed to CCLD by 7/3/2023: admission agreement, resident roster, personnel record (LIC500), physician's report, and any incident reports for May and June 2023, any case/progress notes for May and June 2023.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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-20230628124500
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'S LOVE RCFE
FACILITY NUMBER: 079200741
VISIT DATE: 06/30/2023
NARRATIVE
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Continued from LIC9099.

On the allegation Resident AWOL'ed while under care, during interview with the Staff 1 (S1) via telephone, it was stated that R1 had left the facility two (2) or three (3) months ago (unknown exact date). Staff was not able to find R1 and called the Pittsburg Police Department. S1 stated the Police Department found R1 and returned him unharmed to the facility. S1 also stated that an incident report was not submitted. Based on the investigation the above allegations are SUBSTANTIATED.

On the allegation Resident sustained black eye while under care. S1 stated during interview that she does not know how R1 got the black eye, R1 was possibly hit by his bedroom door. LPA inquired with the three (3) other staff that were present during the visit and all of them stated they were not working on the specific day and do not know how R1 got the black eye.

Based on LPA's interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230628124500
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'S LOVE RCFE
FACILITY NUMBER: 079200741
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2023
Section Cited
CCR
87705(c)(4)
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87705 (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s... safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by:
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Administrator agreed to submit a written plan of correction stating what plan will be implemented to prevent an AWOL from occurring again. Plan will be submitted to CCLD by POC date.
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Based on LPAs interviews and record review the Licensee did not comply with the section cited above in supporting R1's needs, which poses a potential health and safety risk to residents in care.
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Type B
07/10/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 (a) 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:(4) 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. This requirement was not met as evident by.
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Administrator agrees to conduct in-service staff retraining on timely addressing residents’ medical needs and documenting such incidents to CCLD by POC date.
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Based on LPA's interviews and record review the licensee did not comply with the section cited above in providing supervision to care for residents' needs, which poses a potential health and safety 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3