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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201134
Report Date: 11/01/2024
Date Signed: 11/01/2024 12:20:07 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
04/24/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240424150504
FACILITY NAME:ANGEL CARE HOMEFACILITY NUMBER:
079201134
ADMINISTRATOR:WANG, DINGFACILITY TYPE:
740
ADDRESS:1723 LIMEWOOD PLACETELEPHONE:
(925) 635-3936
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 4DATE:
11/01/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Wilfredo Bacani, CaregiverTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility accepted a resident with a higher level of care need.
INVESTIGATION FINDINGS:
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On 11/1/2024 at 11:05am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Wilfredo Bacani, Caregiver and explained the purpose of the visit. Administrator, Ding Wang, arrived at 11:55am.

During the investigation the LPA interviewed staff, witness, obtained and reviewed records.

Allegation: Facility accepted a resident with a higher level of care need.

Based on review of Kaiser medical records R1 was discharged on 4/22/2024. W1 stated during interview that R1 was discharged to Angel Care Home on 4/22/2024 with the

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

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
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-20240424150504
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 CARE HOME
FACILITY NUMBER: 079201134
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC9099.

intentions that staff would be able to assist R1 with conditions that required a skilled professional to handle. W1 stated S1 affirmed that S1 was licensed to aid R1. W1 further stated home health was to begin on 4/23/2024 for R1 but being that the staff was not trained to assist R1 with the level of care that was needed home health denied R1’s admittance to services. W1 stated there was a conversation with S1 and S1 sent R1 to the emergency room. S2 stated during interview that R1 came and left the same day but did not give a date. S1 stated during interview that R1 was discharged to facility on 4/24/2024, on hospice services.

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 date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240424150504
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 CARE HOME
FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2024
Section Cited
CCR
87468.2(a)(4)
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(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 evidence by:
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Administrator agreed to implement a plan to ensure when accepting a resident that requires a higher level of care, supervision, and services the facility will be able to meet their needs and submit plan to CCLD by POC date.
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Based on interviews and record review the Licensee did not comply with the section cited above in providing care and services to meet the resident needs, which poses an immediate 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: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3