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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003809
Report Date: 08/02/2024
Date Signed: 08/02/2024 12:22:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/26/2024 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240726162500
FACILITY NAME:ANGELS HOME LLCFACILITY NUMBER:
306003809
ADMINISTRATOR:ROBERT LEALFACILITY TYPE:
740
ADDRESS:9781 OMA PLACETELEPHONE:
(714) 530-7143
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Mary Lou LealTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff threatened client
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Licensee Mary Lou and discussed the purpose of the inspection.

During the visit, LPA interviewed Resident 1 (R1), Staff 1 (S1), and Licensee.

During their interview, R1 stated that Staff 1 (S1) accuses them of staring while S1 is cooking. Per R1, “a few days ago” they were sitting at the dining table in the facility, when S1’s husband suddenly appeared to confront R1 and told them, “You better stop staring at my wife in the kitchen" and threatened R1 with a closed fist. R1 stated they are not familiar with S1’s husband and they do not know him.

During their interview, S1 stated they called their husband because R1 was staring at them. S1 stated their husband arrived at the facility and told R1 to stop staring.(Cont. LIC9099-C)
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
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 22-AS-20240726162500
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELS HOME LLC
FACILITY NUMBER: 306003809
VISIT DATE: 08/02/2024
NARRATIVE
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During their interview, Licensee confirmed they were aware S1 called their husband and S1’s husband had arrived at the facility and told R1, "stop staring at my wife." Per Licensee, they there present at the facility and informed S1 they should not have called their husband.

Based on S1 and Licensee admission, LPA determined that staff threatened client. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D).

An exit interview was conducted and copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240726162500
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELS HOME LLC
FACILITY NUMBER: 306003809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2024
Section Cited
CCR
87468.1
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...

This requirement is not met as evidenced by:
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Licensee stated they will conduct staff training regarding resident personal rights immediately and a copy provided to LPA via email by POC.
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Based on S1 and Licensee admission, LPA determined that staff threatened client, which poses an immediate safety and personal rights 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: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3