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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320394
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:02:40 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, 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
10/25/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20231025160046
FACILITY NAME:ANGEL'S ON WING'S LLCFACILITY NUMBER:
198320394
ADMINISTRATOR:CLANTON, MARILYNFACILITY TYPE:
740
ADDRESS:1440 W 92ND STREETTELEPHONE:
(310) 684-8859
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY:6CENSUS: 0DATE:
12/08/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marilyn ClantonTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff member physically assaulted resident which in an injury.
Staff abandoned resident.
illegal eviction.
INVESTIGATION FINDINGS:
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On 12/08/2023, Licensing Program Analyst Antonine Richard conducted a subsequent complaint to deliver findings regarding the above allegations. LPA met with Licensee Marilyn Clanton and the purpose of today’s visit was explained. LPA Richard and Licensee Clanton toured the physical plant.

The investigation consisted of the following:

On 10/26/2023, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint investigation. LPA arrived at the facility at 9:00 AM. LPA met with Licensee Marilyn Clanton and the purpose of today's visit was explained. LPA Richard and Licensee Clanton toured the facility. LPA Richard reviewed a prospective client file. LPA interviewed the licensee and collected a copy of the file and a signed declaration letter. LPA also interviewed witness W1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
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 2
Control Number 11-AS-20231025160046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANGEL'S ON WING'S LLC
FACILITY NUMBER: 198320394
VISIT DATE: 12/08/2023
NARRATIVE
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The investigation revealed the following:

Regarding the allegations: “Staff member physically assaulted residents which resulted in an injury.”, “Staff abandoned resident.”, and “Illegal eviction.” It was alleged that a resident from this facility was admitted to the hospital due to injuries and was declined by the licensee when resident was ready to be discharged.

On 10/26/2023 interviewed the reporting party (RP) who denied reporting R1 being physically assaulted by staff at Angel Wings, all they know is that the resident was dumped at the hospital and admitted for three days. LPA interviewed witness W1 a manager at another facility who stated that they received a call from the hospital that a patient was dumped there by an unknown individual. LPA interviewed Licensee Marilyn Clanton who presented a signed written declaration and stated that they have not admitted any residents since they were licensed on 09/20/2023.

On 10/26/2023 LPA conducted a tour of the facility and did not observe any residents or residents’ personal belongings present at the facility.

Based on LPA observation, and interviews, LPA did not find sufficient evidence to support the above alleged allegations. Although the alleged allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged allegations did or did not occur. Therefore, the allegations are Unsubstantiated.

Exit interview conducted and a copy of the report was provided to Licensee Marilyn Clanton.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2