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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201134
Report Date: 07/15/2025
Date Signed: 07/15/2025 03:27:12 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
02/05/2025 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250205174724
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: 6DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Hermino Hernandez, CaregiverTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility staff did not contact emergency services within a timely manner.

Facility staff did not provide consent documents to emergency providers.

Facility staff did not notate resident's medications that were taken.

Facility did not refund responsible party for reminder balance for the month.
INVESTIGATION FINDINGS:
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On 7/15/2025, at 2:25pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Hermino Hernandez, Caregiver. Laly Bascao, Caregiver arrived at 2:25pm and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and review records.

Allegation: Facility staff did not contact emergency services within a timely manner.

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

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 7
Control Number 15-AS-20250205174724
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: 07/15/2025
NARRATIVE
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Continued from LIC9099.

During initial interview W2 stated that emergency services wasn’t called in a timely manner being S1 called R1’s responsible party first and was then instructed to call 9-1-1. W2 further stated R1 was found unconscious and there was not an attempt to resuscitate. S1 stated during interview that due to R1 expiring of natural causes the responsible party was contacted first. S1 stated she was at the facility but was not able to provide what other staff were present.

Allegation: Facility staff did not provide consent documents to emergency providers.

W1 stated during interview that R1 had a physician order for life-sustaining treatment (POLST). W1 stated a lady (unknown name) handed her papers. S1 stated the facility did not have any of R1’s documents and was unsure who took the documents from the facility. During record review of the physician orders for life-sustaining treatment (POLST) dated January 12, 2024, indicated to attempt to resuscitate.

Allegation: Facility staff did not notate resident's medications that were taken.

W1 and W2 stated the facility did not notate any of R1’s medications that were taken. Both feel some of the medications were missing, but it is unknown if R1 had taken the medications or someone at the facility. W2 stated documents were given to W1 and did not indicate that R1 had taken any medications during the time she was there. S1 stated the facility did not have any of R1’s documents. LPA reviewed the medication administration record that was dated May 1, 2025, to May 31, 2024, and there was not any date noted where the

Continued on LIC9099C.

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

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20250205174724
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: 07/15/2025
NARRATIVE
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Continued from LIC9099C.

medication was taken. The Department reviewed pictures of medications that was submitted, however, was unable to determine if medication was taken by R1. W1 stated during interview that a staff gave documents and W1 gave a description of the staff.

Allegation: Facility did not refund responsible party for the remainder balance for the month.

S2 stated during interview that the facility did not refund the balance of the month’s rent. S1 stated that she had an agreement with R1 that there will not be any refund for the 1st month. Health and Safety Regulation 1569.652© states: “A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.”

Based on 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.

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: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
02/05/2025 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250205174724

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: 6DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Hermino Hernandez, CaregiverTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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9
Facility staff did not keep medications inaccessible to resident.
INVESTIGATION FINDINGS:
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On 7/15/2025, at 2:25pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Hermino Hernandez, Caregiver. Laly Bascao, Caregiver arrived at 2:25pm and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and review records.

Allegation: Facility staff did not keep medications inaccessible to resident.

Based on initial interview the facility did not keep medications inaccessible to R1. W1 and W2 stated during interviews that some of R1’s medications

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

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 7
Control Number 15-AS-20250205174724
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: 07/15/2025
NARRATIVE
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3
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Continued from LIC9099.

were in a drawer in the bedroom and some medications were in a gray bag in the closet. S1 stated that R1’s medication was no accessible to R1 during her admission, but all R1’s belongings were in the room for her responsible party.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

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

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20250205174724
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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2025
Section Cited
HSC
1569.652(c)
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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property... (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed... shall be issued to the individual... responsible for the fees... within 15 days after the personal property is removed.
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Administrator agreed to issue a refund to R1’s responsible party and submit documentation to CCLD by POC date.
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This requirement was not met as evidence by:
Based on interviews the Licensee did not comply with the section cited above in refunding responsible party, which poses a potential risk.
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Type B
07/22/2025
Section Cited
CCR
87469(c)(1)
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(c) If a resident who has an... request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: (1) Immediately telephone 9-1-1, present... form to the responding emergency medical personnel...
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Administrator agreed to read and review regulation 87469, and submit a self-certification that the facility will abide by the regulation going forward to CCLD by POC date.
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This requirement was not met as evidence by:
Based on interviews and record review the Licensee did not comply with the section cited above in presenting documents to emergency personnel, which poses a potential health 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: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20250205174724
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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2025
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...
This requirement was not met as evidence by:
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Administrator agreed to implement a plan of what staff shall do when there is circumstance to a resident health including, but not limited to, an apparent life-threatening medical crisis and submit plan to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section cited above in immediately contacting 9-1-1, which poses a potential health risk to persons in care.
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Type B
07/22/2025
Section Cited
CCR
87465(6)
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(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
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Administrator agreed to complete record keeping training by an authorized vendor and submit certifications to CCLD by POC date.
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This requirement was not met as evidence by:
Based on interview and record review the Licensee did not comply with the section cited above in have a MAR for R1, which poses a potential health 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: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7