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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201134
Report Date: 01/30/2025
Date Signed: 01/30/2025 05:25:42 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
11/20/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241120130942
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:
01/30/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Rosalita Constantino, CaregiverTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff did not ensure that resident received medical care after sustaining an injury.

Staff did not ensure resident received medication as prescribed
INVESTIGATION FINDINGS:
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On 1/30/2025 at 12:25pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rosalita Constantino, Caregiver and explained the reason for the visit. LPA spoke with Administrator, Ding Wang, via telephone.

During the course of the investigation the Department conducted interviews with staff, witness, obtained and reviewed records.

Allegation: Staff did not ensure that resident received medical care after sustaining an injury.

Based on initial interview with W2 staff did not ensure R1 received medical care after falling and sustaining an injury. S1 stated R1 fell and sustained injuries at

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

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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 4
Control Number 15-AS-20241120130942
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: 01/30/2025
NARRATIVE
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Continued on LIC9099C.

approximately 3:35am, on November 17, 2024. On November 21, 2024, R1 had a video doctor’s appointment. S1 stated the doctor saw the injury and was not concerned. S1 stated R1’s vitals were checked, he was not bleeding, and he was still walking around, therefore, S1 felt there was not a need for medical attention. S3 stated while doing rounds she observed R1 on the floor and that R1 possibly hit his drawer. S3 stated she did not see any blood and monitored R1’s blood pressure. S3 also stated she contacted S1 but no one else. LPA observed a bruised eye and a cut above R1’s eye during visit on November 21, 2024. LPA also obtained a photo of R1 from S1 of R1’s eye. S1 stated the cut above R1’s eye occurred at another facility. Both S1 and S3 stated that R1 did not receive any medical care after sustaining an injury.

Allegation: Staff did not ensure resident received medication as prescribed

During initial interview with W1 it was indicated that R1 had a medical/phone appointment on November 15, 2024. A new prescription was prescribed on the day of the medical/phone appointment and as of November 20, 2024, the medication had not been picked up by staff to ensure R1 was receiving medication as prescribed. S1 stated during video appointment on November 21, 2024, she asked who will be delivering the medication for R1 and was told the facility needs to pick up the medication. On November 25, 2024, S1 sent an email to LPA with a picture showing three (3) prescriptions that had been picked up for R1.

Continued on LIC9099C.

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

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20241120130942
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: 01/30/2025
NARRATIVE
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Continued from LIC9099D

Based on LPA observations, 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: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20241120130942
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: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
87465(g)
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(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence by:
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Licensee completed a mandated report training by an authorized vendor on 12/23/2024, per the non-compliance meeting held 12/16/2024. Deficiency cleared.
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Based on interviews and record review the Licensee did not comply with the section cited above in contacting 9-1-1 after R1 sustained an injury which poses an immediate health and safety risk to persons in care.
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Type A
01/31/2025
Section Cited
CCR
87465(d)
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(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided... This requirement was not met as evidence by:
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Administrator submitted a photo of medication to CCLD on 11/25/2024. Deficiency cleared.
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Based on observation and record review the Licensee did not comply with the section cited above in obtaining and administering prescriptions as ordered, 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: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4