197607882-8-14-2025-11-AS-JHAD-DL6RZ4-20250903132718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607882
Report Date: 08/14/2025
Date Signed: 08/14/2025 02:49:40 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:	08/14/2025
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Elvira Brondial, Caregiver		TIME COMPLETED:	02:50 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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*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 7/14/25.
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: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

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: 08/14/2025

NARRATIVE

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The investigation revealed the following:

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

It is alleged that R1 was able to walk prior to her admission to this facility, had weight loss and staff did not address the changes. A review of R1’s admission agreement, LPA Felisa Shirley observed that R1 moved into the facility listed above on 5/4/25. On 5/4/25, per the facility’s client weight record, R1 weighed 104.8lbs. Per Kaiser’s medical assessment dated, 5/8/25, the doctor recorded a history of R1’s weight fluctuation from 7/12/23 (112lb 3.4oz), 4/15/24 (112lb 7oz), thru 5/8/25 (107 lb 5.8oz). R1 was non-ambulatory due to both physical and mental conditions per Physician report, dated 5/8/25. 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 that check-up, Kaiser Home Health ordered physical therapy.

LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). Of those interviewed, 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 3 (R-1 – R-3). Of those interviewed, 2 out of 3 denied the allegation.

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: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 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: 08/14/2025

NARRATIVE

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

It is alleged that R1 was hit while in care. During interviews, LPA Shirley interviewed the Administrator and was told that there is no history of elder abuse and no reports of abuse. 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. Per interview with the Administrator, R1 was confused a lot and frequently call out for persons not there. Per Appraisal/Needs and Services dated 5/4/25, R1 can’t verbalize her needs due to memory issues. LPA spoke to W1 and was told that R1’s base prior to being admitted to this facility was confusion and didn’t always recognized family members.

LPA interviewed staff, staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 3 (R-1 – R-3). Of those interviewed, 3 out of 3 denied the allegation.

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: 08/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025

LIC9099 (FAS) - (06/04)

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