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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701111
Report Date: 02/20/2025
Date Signed: 02/20/2025 10:12:25 AM

Unsubstantiated


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
09/10/2024 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240910103111
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:
02/20/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Youngsuk ChoTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not dispense medication to resident as prescribed
Staff did not prevent resident from becoming malnourished while in care
Staff are not meeting resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to deliver findings of the complaint investigation on 2/20/25 at 8:30am. LPA met with Administrator Youngsuk Cho and stated the purpose of the visit.

Regarding allegation, “Staff did not dispense medication to resident as prescribed” LPA observed that the local fire department was called by home health at the request of a visiting nurse. LPA observed a Physician order that discontinued Coumadin 3.5mg and to start 3mg both were 1 tablet at bedtime beginning 8/28/24 and to be rechecked on 9/4/24. LPA interviewed R1 resonsible party on 2/20/25 who stated the facility staff did not make mistakes with medications for R1.Administrator stated that doctor orders are always followed.

Unsubstantiated
Estimated Days of Completion: 120
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 27-AS-20240910103111
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: 02/20/2025
NARRATIVE
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Regarding allegation, “Staff did not prevent resident from becoming malnourished while in care” LPA interviewed R1 responsible party on 2/20/25 who stated R1 was not malnourished while living in the facility and that R1 looked and was doing great. The Administrator stated we feed the residents healthy food, they don't lose weight because of the food.

Regarding allegation, “Staff are not meeting resident's needs” LPA interviewed R1 responsible party on 2/20/25 who stated R1 was well cared for while living at the facility. RP stated visits were frequent and all residents there were getting the proper care they needed. The Administrator stated we do everything the residents need all the time.

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

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

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2