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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881415
Report Date: 03/27/2026
Date Signed: 03/27/2026 10:39:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2024 and conducted by Evaluator Robert Campbell
COMPLAINT CONTROL NUMBER: 18-AS-20240111145220
FACILITY NAME:ANGELICA'S HOME, INC.FACILITY NUMBER:
331881415
ADMINISTRATOR:OOSTING, ANGELICAFACILITY TYPE:
740
ADDRESS:31916 CORTE POSITASTELEPHONE:
(321) 432-8883
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 6DATE:
03/27/2026
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Angelica Oosting/AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not refund authorized representative the proper amount after resident moved out.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Robert Campbell made an unannounced visit to the facility to deliver findings regarding the allegation listed above. LPA met with Angelica Oosting/Administrator and explained the purpose of the visit and the elements of the allegation. LPA conducted an investigation, which consisted of interviews and record review. The department was unable to obtain any additional information from Resident #1 due to their condition.
On January 11, 2024, Community Care Licensing (CCL) received a complaint that alleged staff did not refund authorized representative the proper amount after resident moved out. It was reported that Resident #1 was removed from the home on December 15, 2023 due to an incident. It was reported that Resident’s Responsible Party was refunded $163.50. Resident #1 was placed in the facility in September 2023 and agreed to pay $7,075 monthly, which included the basic rate and memory care services. LPA conducted an interview with Administrator and was advised that Resident’s Responsible Party was refunded the correct amount due to additional charges. (Continue on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Robert Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
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 4
Control Number 18-AS-20240111145220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELICA'S HOME, INC.
FACILITY NUMBER: 331881415
VISIT DATE: 03/27/2026
NARRATIVE
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It was reported that Resident was charged fees pertaining to cleaning and repair services and hardware installation. LPA conducted a review of Resident #1’s monthly billing invoices, Admission Agreement dated 9/07/2023, Pre-appraisal documents, and the facility’s Program Statement/Plan of Operation. The review of documentation did not detail or inform resident’s or their responsible parties regarding refunds pertaining to partial placement or additional charges for damages, additional cleaning services, or reimbursement for additional staffing. The facility failed to notify Resident #1 or Responsible Party of any additional fees prior to the request for the refund. This is in violation of Title 22 regulations, which is a potential risk to residents in care.
Based on interviews and documentation reviewed, the allegation that staff did not refund authorized representative the proper amount after resident moved out is substantiated. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is substantiated. The facility will be cited.
An exit interview was conducted. A copy of the report, along with the LIC 9099-D and appeal rights were provided to **************.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Robert Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20240111145220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELICA'S HOME, INC.
FACILITY NUMBER: 331881415
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2026
Section Cited
CCR
87101
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This 9099 D page was made in error. This page was intentionally left blank
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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: Jazmond D Harris
LICENSING EVALUATOR NAME: Robert Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20240111145220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELICA'S HOME, INC.
FACILITY NUMBER: 331881415
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/10/2026
Section Cited
CCR
87507(g)(B)(2)
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T2287507(g)(B)(2) Admission agreements shall specify the following: Rate for additional items and services, including: A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement. Evidenced by the following:
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Licensee will refund R1 to the POA $522.00, 857.00, & 1745.00 fro a total $3,124.00. Licensee will submit refund receipt to the LPA by POC date.
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LPA reviewed documentation and interviewed Licensee to come to the deficiency.
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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: Jazmond D Harris
LICENSING EVALUATOR NAME: Robert Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4