<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603676
Report Date: 10/21/2025
Date Signed: 10/21/2025 09:31:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2025 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250109162007
FACILITY NAME:FELSON BOARD AND CAREFACILITY NUMBER:
198603676
ADMINISTRATOR:TANGONAN, MARIA ISABELFACILITY TYPE:
740
ADDRESS:13639 FELSON STREETTELEPHONE:
(562) 307-7668
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 6DATE:
10/21/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Maria Isabel TangonanTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights: Staff left resident unsupervised resulting in an injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to deliver findings for the above allegations. LPA met with Maria Isabel Tangonan and discussed the purpose of today’s visit.

On 01/13/25, LPA Irra conducted an initial complaint visit. During this visit, LPA conducted a tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA also reviewed Resident #1 (R-1) files and obtained relevant documentation. Additionally, LPA obtained a copy of the staff schedule and resident roster.

During this investigation, Dennis Douglas (Department of Social Services Community Care Licensing Investigation Branch) interviewed Staff #1 (S-1) through Staff #3 (S-3), R-1’s family member, R-1’s hospice agency and obtained R-1’s medical records from the hospital. **Refer to LIC 9099C for the continuation of this report.**
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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 5
Control Number 28-AS-20250109162007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FELSON BOARD AND CARE
FACILITY NUMBER: 198603676
VISIT DATE: 10/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Personal Rights: Staff left resident unsupervised resulting in an injury. During IBs investigation, it was discovered that on 01/01/25, R-1 experienced a fall at the facility while in the bathroom. It was revealed that R-1 is legally blind. R-1 was initially escorted to the bathroom by S-2 who then momentarily left R-1 in the bathroom while S-2 tended to another resident. S-1 was also present at the facility at that time. Staff interviews revealed that R-1 was equipped with a pendant around R-1’s neck which allows for R-1 to notify staff when R-1 needs assistance. Staff interviews revealed that at the time of the incident, R-1 pressed their pendant alerting them R-1 was done in the bathroom and needed assistance. Interviewed staff indicated they were both tending to other resident at that time and could not assist R-1 in the bathroom right away. During IBs investigation, S-1 also acknowledged that S-1 instructed S-2 to wait because, in the past when R-1 would push the pendant requesting assistance R-1 would not quite be ready. By the time S-2 proceeded to the bathroom to assist R-1, R-1 was discovered laying on the bathroom floor and had already put their diaper on. Interviewed staff indicated they observed an injury to R-1’s left eye as a result of the fall. Per hospital records obtained, as a result of R-1’s fall, R-1 sustained an “impacted femoral neck fracture of the right hip” which required surgery and had a laceration of the left eye cornea. Interviews and documentation corroborate this allegation.

Deficiency cited. Refer to LIC 9099D. Due to the seriousness of R-1’s injuries, an immediate Civil Penalty of $500.00 is being issued during today’s visit.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

An exit interview was conducted. A copy of this report and appeals rights were provided to Maria Isabel Tangonan.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250109162007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FELSON BOARD AND CARE
FACILITY NUMBER: 198603676
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2025
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
PERSONNEL REQUIREMENT. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
1
2
3
4
5
6
7
Administrator to provide an in-service training to staff and discuss the importance of providing adequate assistance in a timely manner to residents.
8
9
10
11
12
13
14
This standard is not met at evidence by:
R-1 fell and sustained injuries while waiting in the bathroom for staff assistance.
8
9
10
11
12
13
14
Administrator to develop and implement a policy pertaining to answering residents’ pendant calls in a timely manner.

Administrator to submit proof of training and a copy of the policy to LPA Irra by POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Wei Siew Ho
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2025 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250109162007

FACILITY NAME:FELSON BOARD AND CAREFACILITY NUMBER:
198603676
ADMINISTRATOR:TANGONAN, MARIA ISABELFACILITY TYPE:
740
ADDRESS:13639 FELSON STREETTELEPHONE:
(562) 307-7668
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 6DATE:
10/21/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Maria Isabel TangonanTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights: Staff did not seek timely medical care for resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to deliver findings for the above allegations. LPA met with Maria Isabel Tangonan and discussed the purpose of today’s visit.

On 01/13/25, LPA Irra conducted an initial complaint visit. During this visit, LPA conducted a tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA also reviewed Resident #1 (R-1) files and obtained relevant documentation. Additionally, LPA obtained a copy of the staff schedule and resident roster.

During this investigation, Dennis Douglas (Department of Social Services Community Care Licensing Investigation Branch) interviewed Staff #1 (S-1) through Staff #3 (S-3), R-1’s family member, R-1’s hospice agency and obtained R-1’s medical records from the hospital. **Refer to LIC 9099C for the continuation of this report. **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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 5
Control Number 28-AS-20250109162007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FELSON BOARD AND CARE
FACILITY NUMBER: 198603676
VISIT DATE: 10/21/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Personal Rights: Staff did not seek timely medical care for resident in care. During IBs investigation, it was discovered that on 01/01/25, staff called the Administrator/S-3 and informed S-3 of R-1’s fall. Per staff interviews, staff notified S-3 of R-1’s fall within “minutes” of the incident. Per interviews, S-3 contacted R-1’s family member and hospice agency and informed them of R-1’s fall. Staff interviews revealed that staff did not call 911 at that time as R-1 was receiving hospice services (the protocol is to contact the hospice agency prior to calling 911 as hospice services may be interrupted when calling 911). Per interviews, R-1’s family member and hospice agency nurse arrived to this facility within approximately 30 minutes to assess R-1. R-1’s family member decided to take R-1 to the hospital for further evaluation. Interviews do not corroborate this allegation.

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

Exit interview was conducted and a copy of this report and appeal rights were provided to Maria Isabel Tangonan

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5