197607882-7-14-2025-11-AS-JHAD-DL6RZ5-20250903132719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607882
Report Date: 07/14/2025
Date Signed: 07/14/2025 04:05:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2025 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20250707102935

FACILITY NAME:	ANGEL ASSISTED LIVING SERVICES		FACILITY NUMBER:	197607882
ADMINISTRATOR:	ELVIRA CLAVERIA		FACILITY TYPE:	740
ADDRESS:	4401 234TH PLACE		TELEPHONE:	(310) 373-9275
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 5	DATE:	07/14/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Elvira Brondial, Caregiver		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff did not address a resident's change in medical condition
Staff did not prevent a resident from being hit while in care

INVESTIGATION FINDINGS:

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On 7/14/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Administrator, Leia Joaquin and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:
On 7/14/25 LPA requested and reviewed copies of the following records: Resident files, Resident Roster, Staff roster, Identification and Emergency Information, Admission Agreements, Physician’s Report, Preplacement Appraisal, Appraisal Needs and Services, Weight Record, and After Visit Summaries. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-6. S-7 is listed on the roster but is an on-call only employee and has not worked at the facility as of yet and was not interviewed. LPA Shirley interviewed Resident 1 - Resident 3. Resident 4,5 and 6 were not available for interview.

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

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 3

Control Number 11-AS-20250707102935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ANGEL ASSISTED LIVING SERVICES	FACILITY NUMBER: 197607882
	VISIT DATE: 07/14/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not address a resident's change in medical condition

On 7/14/25, LPA Felisa Shirley reviewed R1’s Admission Agreement and observed that R1 moved into the facility listed above on 5/4/25. LPA Shirley reviewed R1’s Physician report, dated 5/8/25. During record review, LPA observed that R1 was non-ambulatory due to both physical and mental conditions. LPA Shirley observed the section, Physical Health status for Motor Impairment/Paralysis and saw that due to R1’s gait instability a walker was ordered on 5/8/25. LPA Shirley reviewed the Resident Appraisal for R1 and observed the Physical Disabilities section and it stated that a front wheel walker was ordered due to balance issues. During file review, LPA Shirley observed that R1 had a check-up on 5/19/25. During the check-up, Kaiser Home Health for Physical Therapy was ordered.

LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). LPA asked, does staff address residents change in medical conditions while in care. Of those interviewed 6 out of 6 stated yes. LPA interviewed resident 1 – resident 3 (R-1 – R-3). LPA asked residents, does staff address your changes in medical conditions while in care. Of those interviewed, 2 out of 3 answered yes, and 1 answered no.

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250707102935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ANGEL ASSISTED LIVING SERVICES	FACILITY NUMBER: 197607882
	VISIT DATE: 07/14/2025

NARRATIVE

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Allegation: Staff did not prevent a resident from being hit while in care

On 7/14/25 LPA Felisa Shirley reviewed R1’s Preplacement Appraisal, dated 5/5/25. Upon review, LPA observed that R1 has difficulty communicating due to memory issues from dementia. LPA Shirley reviewed R1’s Physician’s Report dated, 5/8/25. During record review LPA Shirley observed that R1 was diagnosed as having dementia. During interviews, LPA Shirley ask R1 has anyone hit her while in care and R1 answered no.

LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). LPA asked, does staff prevent residents from being hit while in care. Of those interviewed 6 out of 6 stated yes. LPA interviewed resident 1 – resident 3 (R-1 – R-3). LPA asked residents, does staff prevent residents from being hit while in care. Of those interviewed, 3 out of 3 answered yes.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to Elvira Brondial.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

LIC9099 (FAS) - (06/04)

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