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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530240
Report Date: 09/11/2025
Date Signed: 09/11/2025 12:42:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
07/29/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250729201506
FACILITY NAME:ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLCFACILITY NUMBER:
335530240
ADMINISTRATOR:MAZARIEGOS, JOHNNYFACILITY TYPE:
740
ADDRESS:36785 BRAKEN WAYTELEPHONE:
(951) 452-1216
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY:6CENSUS: 4DATE:
09/11/2025
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Facility Staff-Care Giver Gilbert OteyzaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not meeting resident's hygiene needs.
Due to staff neglect, resident sustained pressure injury while in care.
Staff are not meeting resident's toileting needs.
INVESTIGATION FINDINGS:
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On 09/11/2025, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced complaint visit to the facility to deliver findings. LPA met with Facility Staff-Care Giver Gilbert Oteyza and discussed the purpose of the visit. The investigation consisted of observations, record reviews and interviews with pertinent parties.
Regarding the First allegation, Staff are not meeting resident's hygiene needs. LPA Singh observe staff at the facility taking care of the hygiene needs of the residents. LPA Singh Interviewed two (2) staff and two (2) residents, Two(2) out of two(2) staff and two(2) out of three (3) Clients stated there are no concerns with staff not meeting hygiene needs of the residents. Also,Staff and residents stated that staff take good care of the hygiene needs of the residents in care.
Second allegation: - Due to staff neglect, residents sustained pressure injury while in care. LPA Singh reviewed resident care records and observed staff providing good care to residents. Interviews with two (2) staff and two (2) residents reveal there are no concerns with staff care and no staff neglects residents and staff help residents in moving or transferring from bed, no issues of pressure injury.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
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 2
Control Number 56-AS-20250729201506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGEL'S HAVEN CARE ASSISTED LIVING ELSINORE LLC
FACILITY NUMBER: 335530240
VISIT DATE: 09/11/2025
NARRATIVE
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LPA Singh reviewed R#1’s records review and Resident #1 (R#1) record review showed a history of UTIs (urinary tract infections) and cellulitis. This medical history puts R#1 at a higher risk for skin breakdown. Despite this risk, staff are actively taking measures to prevent skin issues. Staff ensures R#1 is kept clean and dry and assist with turning in bed. It was also noted that R#1 prefers to use a bedpan without help from facility staff. Home Health care visited R#1 once a week and R#1 developed blisters on the legs after staying in the hospital for a week admitted on 07/28/2025, R#1 has been discharged from hospital to home on 08/06/2025. Home health visited facility twice a week for the wound care after R#1 sustained blisters during R#1's stay in the hospital.

Third allegation: - Staff are not meeting residents’ toileting needs.

Interviews with two (2) staff and two (2) residents reveal there are no concerns with Staff are not meeting residents’ toileting needs. Staff always help the residents in meeting the toileting needs of the residents in care. It was also noted that R#1 preferred to use a bedpan without help from facility staff.

Based on the Department's investigation, the allegations- Staff are not meeting resident's hygiene needs, Due to staff neglect, resident sustained pressure injury while in care and Staff are not meeting resident's toileting needs above are Unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy provided to Facility Staff-Care Giver Gilbert Oteyza.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2