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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205039
Report Date: 03/08/2022
Date Signed: 03/08/2022 11:43:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2022 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220301144006
FACILITY NAME:ANGEL'S HAVEN IIFACILITY NUMBER:
198205039
ADMINISTRATOR:OSCAR LECHUGAFACILITY TYPE:
740
ADDRESS:28022 ACANA ROADTELEPHONE:
(310) 544-4594
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 4DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Vicenta Mendoza, LicenseeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff not following masking requirements in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Vicenta Mendoza, the facility Licensee.

The investigation consisted of following: Interviews, record review, and observations. LPA Soto interviewed Licensee, S#1, R#1 - R#4. Received the following documents on 03/08/22: Roster and Staff Schedule. Toured rooms 1 & 2, dining room, living room, and kitchen.

Based on the LPA's investigation, the investigation revealed the following. For Allegation – Staff not following masking requirements in the facility. Interviews with licensee, S#1, R#1, & R#2, stated that the staff do not wear mask. Licensee stated that they do not wear mask because no one leaves the facility. The son buys everything the facility needs and brings it to them. The visitors are admitted but they stay outside in the patio to visit with their family members. LPA attempted to interview R#3 & R#4, due to their mental disablities they could not undertsand and/or communicate with LPA. LPA Soto observed that the Licensee and S#1 did not have mask on when LPA arrived at the facility.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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-20220301144006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANGEL'S HAVEN II
FACILITY NUMBER: 198205039
VISIT DATE: 03/08/2022
NARRATIVE
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The Licensee and S#1 put on their masks when LPA Soto explained the need for them and prompted them too.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Vicenta Mendoza, Licensee and a copy of Report and Appeal Rights provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220301144006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANGEL'S HAVEN II
FACILITY NUMBER: 198205039
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2022
Section Cited
CCR
87470(b)(2)
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All staff and volunteers providing direct care to a resident who has a communicable disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.
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Licensee will instruct and perform training with all staff on when and how to wear mask while working at facility. To send LPA Soto a signed training sheet all of staff attending.
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This was not met as evidence by: Based on observations and interviews staff were not wearing masks. 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: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3