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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006257
Report Date: 02/11/2026
Date Signed: 02/11/2026 04:27:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/21/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240521100241
FACILITY NAME:ANGELS CARE GUEST HOME IIFACILITY NUMBER:
306006257
ADMINISTRATOR:JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:432 N. COLORADO STREETTELEPHONE:
(714) 244-5885
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 6DATE:
02/11/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ruby CruzTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Due to neglect, resident sustained a pressure injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Licensee Ruby Cruz and explained the reason for the visit. The investigation into the allegation revealed the following. Resident 1 (R1) moved into the facility on October 1, 2023. R1 was admitted to hospice when they moved into the facility. R1 was diagnosed with Parkinson Disease. A hospice nurse visited R1 twice a week. Staff interviewed reported they followed all hospice orders and wound care orders for R1. The Administrator reported that facility staff followed all the orders from hospice and wound care and R1 was cleaned and changed regularly. A review of records shows that R1 was diagnosed with a new pressure injury in the coccyx area on December 24, 2023. R1’s responsible party reported they were notified by hospice on December 30, 2023, of a stage 2 pressure injury and that treatment was started. Hospice ordered the resident to be clean, and dry and the wound area to be cleaned and dried daily along with new bandages every day and for R1 to be repositioned every 2 hours. On January 29, 2024, hospice orders indicate that the pressure injury should be cleaned and bandages changed every day and describe the pressure injury as stage 2/3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
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-20240521100241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELS CARE GUEST HOME II
FACILITY NUMBER: 306006257
VISIT DATE: 02/11/2026
NARRATIVE
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On February 2, 2024, a referral to wound care was submitted and R1 was accepted into wound care on February 7, 2024. R1 was still on hospice to manage their comorbidities. R1 was visited by a wound care nurse once a week from February 7, 2024, to May 2, 2024. Records were requested for the visit that should of took place on May 9, 2024, but none were provided. A review of records shows the wound progressed from stage 2 to stage 3 and then unstageable and increased in size. On February 29, March 7, April 11, April 18 the wound was listed as improving, but overall, the wound increased in size and on April 26, 2024, the wound was diagnosed as infected. On May 18, 2024, the responsible party requested R1 be transferred to the hospital because the wound was not healing. R1 was diagnosed with a wound on December 24, 2023. Under hospice care the wound did not improve and wound care was ordered and approved. Under wound care the wound did not heal, increased in size and finally became infected and R1 was sent to the hospital due to the wound. Even though the staff rotated R1 as directed by hospice and wound care, R1’s wound never improved at the facility. It is unknown how often the wound was cleaned and bandages changed. A review of the photographic evidence shows the wound increased in size from February 2, 2024, to May 2, 2024. After 2 months of treatment the wound did not improve and increased in size, the resident remained at the facility and no changes to R1's plan care were made. The resident was on hospice but none of the notes show the resident was having any issues with their primary diagnosis of Parkinson Disease. On May 18, 2024, the resident was transported to the hospital at the request of the responsible party. The responsible party reported that once they notified the primary care physician of the situation they recommended R1 be transferred to the hospital. Facility staff reported that they were informed that R1 was being transferred to the hospital. After R1 was transferred it is unknown what happened to R1. R1’s responsible party did not respond to requests for an interview after May 28, 2024. The hospice nurse listed in the hospice records did not respond to requests for an interview. The wound care nurse interviewed had no direct knowledge of Resident 1 but assisted in providing the records. Based on the evidence gathered the preponderance of evidence standard has been met; therefore, the allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted, and a copy of this report and appeal rights were discussed with and provided to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240521100241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ANGELS CARE GUEST HOME II
FACILITY NUMBER: 306006257
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2026
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by:
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Licensee agrees to train care staff on CCR 87464 and to submit proof of training to LPA.
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Based on the evidence gathered, the licensee did not ensure R1 received care and supervision, as a result R1 suffered a pressure injury that required hospitalization, which poses an immediate health and safety risk to persons in care. CIVIL PENALITY ASSESSED.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3