<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201134
Report Date: 01/30/2025
Date Signed: 01/30/2025 05:51:16 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
08/26/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240826114945
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:
02:10 PM
MET WITH:Rosalita Constantino, CaregiverTIME COMPLETED:
02:27 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not ensuring facility bathroom is maintained in good repair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/30/2025 at 2:10pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rosalita Constantino 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, witnesses, and toured facility.

Allegation: Facility staff not ensuring facility bathroom is maintained in good repair

Based on observation the shared bathroom was in disrepair. S1, S2, and S3 stated during interviews that caregivers use the master bathroom to give baths to residents.

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 6
Control Number 15-AS-20240826114945
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099.

Based on LPA observation and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.

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 6
Control Number 15-AS-20240826114945
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 B
02/06/2025
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:
1
2
3
4
5
6
7
The administrator repaired the bathtub and submitted photos to CCLD on 11/13/2024. Deficiency cleared.
8
9
10
11
12
13
14
Based on observation the Licensee did not comply with the section cited above in having the tub in the shared bathroom in repair, which poses a potential health and safety risk to person in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 3 of 6
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
08/26/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240826114945

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:
02:10 PM
MET WITH:Rosalita Constantino, CaregiverTIME COMPLETED:
02:27 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff handles resident(s) in a rough manner

Facility staff yells at resident(s)

Facility staff unable to communicate with residents and others due to language barrier

Facility staff not ensuring adequate amount of food is stored at facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/30/2025 at 2:10pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rosalita Constantino 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, and toured facility.

Allegation: Facility staff handles resident(s) in a rough manner

Based on initial interview with W1 it was stated male staff yanks the arm of R1. W1

Continued on LIC9099C.

Unsubstantiated
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: 4 of 6
Control Number 15-AS-20240826114945
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099.

did not mention observation of this to R1 or any other residents. R1 was not interviewed due to diagnosis. Staff stated during interviews that no one handles any of the resident roughly. LPA was not able to interview W1.

Allegation: Facility staff yells at resident(s)

W1 stated during initial interview that R1 is hard of hearing and staff yells at R1. Based on LPA's observation the staff do yell in order for R1 to hear them. LPA observed R1 asking staff to speak up. Staff stated they are not yelling to be malicious, but R1 can't hear them.

Allegation: Facility staff unable to communicate with residents and others due to language barrier

W1 stated during in initial interview there were three (3) staff that are not able to communicate with the residents due to a language barrier. S1 stated all staff are able to communicate. Some have heavier accents than others but all can communicate. LPA interviewed the staff in question S2, S3, and S4. S2 had the heavier accent and did not understand everything LPA but was able to answer and communicate. The other two (2) staff in question did not have a communication problem. LPA observed all three (3) of the staff in question communicate with the residents.

Allegation: Facility staff not ensuring adequate amount of food is stored at facility

W1 stated during initial interview that there is never an adequate amount of food at facility. LPA's initial visit was 8/30/2024, and LPA observed facility had food on that date. S3 stated during interview that facility does run short of food a lot. S3 said he has

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: 5 of 6
Control Number 15-AS-20240826114945
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099C.

purchased some food items before. S4 stated he doesn't do any cooking that he only cleans the kitchen. S1 stated the staff will advise and make a list of foods to purchase. On today's date LPA observed facility had a sufficient amount of perishables, non-perishables, and snacks.

Based upon the information obtained during and the interviews conducted during the investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.
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: 6 of 6