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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701111
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:30:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2024 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20240606204602
FACILITY NAME:AN ANGEL GARDEN INCFACILITY NUMBER:
342701111
ADMINISTRATOR:CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:9873 TRAVELER COURTTELEPHONE:
(530) 886-9529
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Youngsuk ChoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff neglect resulted in a resident to sustain multiple pressure injuries
Staff interfered with a resident's visitations
Staff did not seek timely medical attention for a resident
Staff unable to properly assist a resident while in care
Resident sustained an unexplained injuries while in care
Staff did not properly report incidents involving a resident
Staff unlawfully evicted a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to deliver the findings of the investigation on 10/25/24 at 2:00pm. LPA met with Administrator Youngsuk Cho and stated the purpose of the visit. Regarding allegation, “Staff neglect resulted in a resident to sustain multiple pressure injuries”, LPA observed a text between Responsible party and Administrator dated 5/20/24, Administrator informed responsible party R1 was scratching buttock and back at which time Administrator stated, “So I have been doing wound treatment every day and dressing”. On 5/30/24, the responsible party stated that a nurse will come out on 5/31/24 to assess R1 which was coordinated with the doctor.
A review of the Preplacement Appraisal Information dated 6/30/22 indicates incontinence care every 2hrs applying bowel and bladder program to prevent UTI and any other skin breakdown.
Appraisal/Needs and Services Plan dated 7/1/22 indicates under background information skin break down; under Physical/Health Incontinent B/B with high risk for UTI, skin breakdown objective/plan no skin irritation, no UTI/No skin issues (next eval June 23), assessment 8/29/23 indicates total incontinent of B/B (bowel and bladder) will be clean and dry, no skin issue (next eval July 24).
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 10
Control Number 27-AS-20240606204602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AN ANGEL GARDEN INC
FACILITY NUMBER: 342701111
VISIT DATE: 10/25/2024
NARRATIVE
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A review of the Home Health dated 6/3/24 notes revealed a pressure injury at stage 2 (Left Thigh) which is allowed in residential facilities. However, it also revealed that R1 had a pressure injury at stage 3 (Right ankle) and a pressure injury at stage 4 (Coccyx) and (Lower Back), and a pressure injury which was unstageable (Right Thigh). A review of the hospital medical records dated 6/4/24, revealed R1 as non-verbal, Mid-back, stage 3, Sacrum, stage 4, Right hip, unstageable, Left hip, unstageable.
LPA observed that R1 was not receiving hospice care services while residing in the facility.
During an interview on 9/18/24 the Administrator stated the wound got worse within 2 weeks. Based on the Administrator being aware of the 5 pressure injuries 4 of which are deemed prohibited, this allegation is deemed substantiated.

Regarding allegation, “Staff interfered with a resident's visitations”, A review of the Admission Agreement signed and dated 6/18/22 regarding visitation, LPA observed the visiting hours to be 9a – 7p requesting that all visitors sign in and be respectful to other residents and staff. After 8p or before 8a visits, they are requested to ring the doorbell. Administrator also asked if they could call as a courtesy so staff can expect them.
Interviews revealed that R1 had visitors and was never refused. S1 stated that there was a visitor who wanted to see R1’s body and the visitor was told not to violate the residents’ personal rights. A review of documented “Texts” revealed that RP usually informs Administrator when visits will be conducted and who will arrive. Administrator was aware that a nurse was coming to assess R1. LPA observed an email from Administrator to responsible party indicating time to visit is 9a-1p and that after 4p is the staff’s busiest time. If there are special circumstances requiring visits during this time visits may occur after contacting staff in advance. On 5/20/24 at 9:20am the responsible party attempted to arrange a 6:30p visit via text and Administrator responded could it be before 3-4p because at 6:30p is too late for other residents and R1 goes to bed at 5p. The Administrator discovered it wasn’t family but other facilities looking to assess and was not aware the family was looking at other placement options and they were looking to no longer having resident at the facility. Based on visiting policy in the admission agreement which indicates the hours of 9-7p and Administrator admittance in stating no is evident that the administrator did not uphold the admission agreement visiting policy.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 27-AS-20240606204602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AN ANGEL GARDEN INC
FACILITY NUMBER: 342701111
VISIT DATE: 10/25/2024
NARRATIVE
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Regarding allegation, “Staff did not seek timely medical attention for a resident”, LPA observed that on
5/30/24 a text revealed that Responsible Party mentioned a nurse would come to assess R1 and the physician will be contacted.
On 5/31/24 the nurse was requested.
On 6/1/24 Responsible Party stated in text a friend of family (nurse) will arrive on 6/2/24.
On 6/2/24, the nurse and doctor indicated R1 may have pressure injuries and to repositioned.
On 6/3/24 nurse and Responsible Party arrived at which time, the nurse staged the pressure injuries to be stage 4 and for R1 to be non-emergency transported to ER. Administrator suggested calling 911 rather than wait to transport for an hour.
Based on information received from documentation and interviews, the following deems this allegation to be SUBSTANTIATED:
-A review of text message on 5/20/24, the Administrator notified the responsible party regarding a wound on R1
-A review of the preplacement Appraisal dated 6/30/22 which indicated R1 is a risk of skin breakdown
-Administrator was trying to manage the wounds instead of sending R1 to see a skilled medical professional.
-R1 did not receive medical attention for the wound(s) until 14 days later.
The investigation revealed that Administrator did not activate 911 until the visiting nurse mentioned a non-emergency transport was called.

Regarding allegation, “Staff did not properly report incidents involving a resident”, LPA received information through interviews that R1 had a head injury on or about 3/27/23 where the responsible party was not notified in a timely manner and there was a R2 who fell on or about 9/28/22 where R1’s responsible party was asked to assist in lifting the resident. R2 is no longer living in the facility. Upon a research of files, LPA did not observe an LIC624 for either incident. Allegation is deemed SUBSTANTIATED

Regarding allegation, “Resident sustained an unexplained injury while in care” LPA received information through interviews that R1 sustained bruises to the head and mouth between the dates of May 4th through May 20, 2024 from a fall. These bruises were brought to the attention of the responsible party by photos sent by staff who were not sure on how the bruises happened. Allegation is deemed SUBSTANTIATED
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 27-AS-20240606204602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AN ANGEL GARDEN INC
FACILITY NUMBER: 342701111
VISIT DATE: 10/25/2024
NARRATIVE
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Regarding allegation, “Staff unable to properly assist a resident while in care”, LPA obtained information that the Administrator was providing wound care at the facility. LPA observed a text message from Administrator to the family stating she was providing the wound treatment every day and dressing with calmoseptine.

Due to this information from interviews and medical records review, Community Care Licensing (CCL) finds this allegation(s) to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client. The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49 is currently under review (pending determination) and may be assessed on a later date, as a result of R1’s sustaining pressure injuries (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Licensee representative and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 27-AS-20240606204602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AN ANGEL GARDEN INC
FACILITY NUMBER: 342701111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3, (1) stage 4 and (2) unstageable pressure injuries.
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Administrator shall provide confirmation of understanding of this regulation. POC will be faxed by POC due date
You are hereby assessed a Civil penalty in the amount of $500.
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This regulation was not met as evidence by: The licensee did not ensure that persons having prohibited health conditions were not retained in the facility. Based on documentation, R1 had 3 unstageable pressure injuries. This poses an immediate risk to residents in care.
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You are hereby assessed a Civil penalty in the amount of $500.
Type A
10/26/2024
Section Cited
CCR
87507(f)
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Admission Agreements
The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
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Administrator shall provide confirmation of understanding of this regulation.

POC will be faxed by POC due date

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This regulation was not met as evidence by: Based on Licensee did not ensure visitation rights as stated in the admission agreement. This poses an immediate risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 27-AS-20240606204602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AN ANGEL GARDEN INC
FACILITY NUMBER: 342701111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Administrator shall provide confirmation of understanding of this regulation.

POC will be faxed by POC due date
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This regulation was not met as evidence by: Based on Licensee did not ensure R1 was seen by a licensed skilled professional timely. This poses an immediate risk to residents in care.
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Type A
10/26/2024
Section Cited
CCR
87211(a)(1)
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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee shall submit a letter stating that incidents that occur with residents shall be reported to CCL in accordance to the regulations.

POC will be faxed by POC due date
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This regulation was not met as evidence by: Based on Licensee did not report in writing to CCL about resident falls in the facility. This poses an immediate risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 27-AS-20240606204602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AN ANGEL GARDEN INC
FACILITY NUMBER: 342701111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
87468.1(a)(8)
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Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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Licensee shall submit in writing that Responsible parties will be kept informed regarding the care of residents.

POC will be faxed by POC due date
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This regulation was not met as evidence by: Based on Licensee did not report to the responsible party timely regarding 2 falls for R1. This poses an immediate risk to residents in care.
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Type A
10/26/2024
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions
Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries.
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Licensee shall submit a letter stating that all wounds shall be diagnosed by a physician, medications to be prescribed and wound care conducted by licensed skileed professional.

POC will be faxed by POC due date
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This regulation was not met as evidence by: Based on Licensee did not ensure R1 was seen by a physician for wounds and provided wound care at the facility.
This poses an immediate risk to residents 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: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2024 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20240606204602

FACILITY NAME:AN ANGEL GARDEN INCFACILITY NUMBER:
342701111
ADMINISTRATOR:CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:9873 TRAVELER COURTTELEPHONE:
(530) 886-9529
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Youngsuk ChoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff mishandled a resident while in care
Staff did not provide adequate supplies to meet the resident's needs
Staff intimidated a resident while in care
Staff allowed a resident to be soiled while in care
INVESTIGATION FINDINGS:
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Regarding allegation, “Staff mishandled a resident while in care”, LPA received information through interviews that on May 27, 2024, that the Responsible party of R1 visited and witnessed R1 being restrained by the neck with the Administrators arm and elbow holding R1’s neck down in the bathroom so that R1 would not scratch during incontinence care in the bathroom. During an interview with the Administrator LPA obtained information that this incident never occurred because there was always 2 persons assisting R1 in the bathroom. LPA did not have sufficient evidence to substantiate the allegation.

Regarding allegation, “Staff did not provide adequate supplies to meet the resident's needs” LPA obtained information that R1’s responsible party was providing supplies such as gloves, wipes, under pads for bed and/or depends. A review of the initial admission agreement page 4 #3 under rate for optional services LPA observed “(NA)” and did not observe any initials for this service. Interviews revealed there was a verbal agreement since admittance on 6/2022.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 27-AS-20240606204602
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AN ANGEL GARDEN INC
FACILITY NUMBER: 342701111
VISIT DATE: 10/25/2024
NARRATIVE
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LPA observed that on 5/21/24 a text from responsible party that indicated supplies will be delivered to the facility. LPA did not observe any written agreement stating the responsible party will or not provide supplies. Based on interviews, the verbal agreement was continued from June 2022 until R1 left the facility.

Regarding allegation, “Staff intimidated a resident while in care” LPA received information through interviews that Administrator was observed to have a bad “tone” when speaking with R1. LPA obtained information through interviews that a visitor observed Administrator raise a hand at another resident on or about August or September 2023 and when questioned, the Administrator stated they were joking around. However, the resident is no longer residing in the facility.

Regarding allegation, “Staff allowed a resident to be soiled while in care” LPA received information that although R1 did not have a foul body odor, upon arrival of visitation, R1’s clothing and gauze was soiled in the area of the wounds. During interviews, LPA obtained information that R1 did not have a body odor and the home was clean. LPA was unable to obtain a preponderance of evidence to substantiate the allegation.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Licensee representative and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2024 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20240606204602

FACILITY NAME:AN ANGEL GARDEN INCFACILITY NUMBER:
342701111
ADMINISTRATOR:CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:9873 TRAVELER COURTTELEPHONE:
(530) 886-9529
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Youngsuk ChoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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5
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9
Staff unlawfully evicted a resident
INVESTIGATION FINDINGS:
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Regarding allegation, “Staff unlawfully evicted a resident”, LPA did not obtain information that R1 was evicted from the facility. LPA reviewed a text indicating some of R1’s, belongings were picked up on 6/5/24. On 6/7/24, all belongings were removed. The Administrator and Responsible party concur that an eviction was not given verbally or in writing to R1 or the Responsible Party. LPA observed an email from R1’s responsible party as a 30day notice to Administrator dated 5/30/24. LPA received a copy of a text from Administrator sent on 5/28/24 to an agency asking for assistance in placement for R1 as she received a 30day notice call from R1’s family on 5/24/24. LPA also observed an email from R1’s family issuing a 30-day notice to the facility. Based on interviews the allegation is deemed Unfounded. "The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.
Unfounded
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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