Angels Senior Care Home

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) David Marrufo and Simi Rai conducted an unannounced Required - 1 Year visit and met with Xi-Hua "Julia" Luo. During visit, LPAs toured the facility inside and out. LPAs toured the kitchen area and observed there to be locked storage areas for sharp objects and medications. LPAs observed the kitchen refrigerator had the following medications stored without being inside a locked container: Medications M1-M4, belonging to R1, and Medication M5, belonging to R2. LPAs observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. During visit, LPAs toured six out of six resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPAs tested the carbon monoxide and smoke detectors in the hallways and six out of six resident bedrooms and all detectors function properly when tested. LPAs toured five out of five resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks ranged from 106 F to 107 F. LPAs toured the outside areas and observed the outdoor exits were clear of obstructions. See LIC812-C page for more information. Page 1 of 2. LPAs reviewed five out of five resident records and three staff records and found them to be complete. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. LPAs request that the following documents be updated and copies sent to the department by 01/21/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610 Emergency Disaster Plan This report was reviewed with Administrator Xi-Hua "Julia" Luo and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Jan 14, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Santino Fortes & Christine Dolores conducted an unannounced annual inspection, and met with Caregiver Licensee Yu Zhang. Licensee informed that facility has 3 staff and 6 clients. LPAs toured the facility inside out including: kitchen, living room, family room and 1 staff room, 6 resident rooms and 4 restrooms. Restrooms observed to have non-skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least seven days. Refrigerator temperature was observed at 42 degrees F and Freezer temperature was 0 Degrees F. The front yard and backyard of the facility was also inspected. There was no obstruction to block the outdoor exits. Two storage sheds were observed. Storage shed on east side of of backyard was observed to be used for storage. The west side storage shed was observed to be used as a living space by staff. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 74 degree F, and hot water temperature was initially measured at 149.0 in the hallway bathroom and 151.1 degrees F from a resident bathroom. Licensee adjusted the water temperature during visit. The hot water temperature measured from resident bathroom at 105 degrees F and 106 degrees F in the kitchen. LPA inspected the facility first aid kit and it was observed to be complete. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested. Fire extinguishers were last serviced on 7/11/24. The facility last fire drill was conducted on 3/27/24. LPA reviewed facility records for 5 staff and 6 clients. LPA reviewed 6 clients medications and centrally stored medication records and observed to be accurate . Deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with Licensee. This report was reviewed and a copy was provided to Licensee for signature.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst’s Manuel Monter and Mita Partoza conducted an unannounced case management visit to follow up on deficiencies that were cited on a previous visit,dated January 27, 2024. LPAs met with Administrator Xi-Hua Luo and explained the purpose of the visit. On April 4, 2024, Licensing Program Analysts asked ADM to show the backyard sheds. ADM stated she does not have the keys to the sheds and could not show LPA's the inside of the sheds. LPA spoke with ADM and ADM confirmed that she would send an updated plan of correction regarding staff sleeping in the backyard sheds. During visit, LPA's observed the a section of fence in the backyard was in disrepair. ADM stated the fence in the backyard had multiple boards came loose due to the storm. ADM stated she is collaborating with her neighbor and will fix the fence as quickly as possible. This report was reviewed with Administrator (ADM) Xi-hua Luo . A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024

Type of visit: Case Management - Other

Licensing Program Analyst Manuel conducted an unannounced case management visit to amend a facility evaluation report that was issued on January 27, 2024, to add additional information. LPA met with Administrator Xi-Hua Luo and explained the purpose of the visit. No deficiencies cited. A copy of the report was provided to Administrator Xi-Hua Luothe state’s words, verbatim · CDSS document, Feb 21, 2024

Allegation investigated: Staff hits resident. Staff yells at resident. Staff handles residents roughly.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint investigation visit to deliver the investigation finding and met with administrator (ADM) XI-HUA LUO. On 04/08/2022, the Department received a complaint with the above allegations. On 4/14/2022, LPA conducted an initial complaint investigation visit, LPA interviewed ADM, two staff (S1, S2), and 6 residents. Residents' Physician reports, Appraisal Needs and Services Plans of residents, and admission agreement were obtained. Continued on 9099-C. Page 1 of 2. Unsubstantiated Staff hits resident. Staff yells at resident. Staff handles residents roughly: On 4/14/2022, LPA interviewed resident R1. R1 stated no one hit him/her or was rough with him/her, and no one yelled at him/her. R1 stated he/she was not aware of anyone hit or yelled at other residents. LPA interviewed resident R2, R2 denied that any staff hit or yelled at him/her. R2 stated he/she did not see or hear any staff hit or yell at residents. R2 stated staff were not treated him/her roughly. LPA checked resident R1 and R2 with ADM, there were no bruises found on R1's and R2's bodies. LPA interviewed staff S1. S1 stated he/she did not hit residents, was not rough with residents, did not yell at residents, nor did he/she see or hear staff hit residents, was rough with residents, or yelled at residents. LPA interviewed staff S2. S2 denied that he/she hit the residents, was rough with residents, or yelled at residents. S2 stated he/she did not hear or see any staff hit residents or yell at residents. S2 stated the allegations were not true. LPA interviewed ADM. ADM stated he/she did not receive any reports regarding that staff hit residents, yelled at residents, or handled residents roughly. ADM stated he/she did not see or hear these allegations. ADM stated he/she interviewed staff, and all staff denied the allegations. Based on the investigation and interviews, there was no evidence for the allegations. The Department has investigated the above allegations. Based on interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Exit interview conducted with ADM. This report was provided for signature. A copy of this report was provided to ADM. Page 2 of 2.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 26-AS-20220408121347

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Xi-hua Luo . During visit, LPA observed 5 residents and 2 staff. (This duplicated report is being amended, due to being created erroneously.) LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 6 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. While touring the back yard, at 8:44am, LPA observed a shed, directly across from the sun room. ADM stated this is a staff room, where her staff member sleeps. ADM knocked on the shed, and a staff member with a pink robe exited. LPA interviewed staff S1. S1 stated he/she sleeps in the shed. Based on a review of the facility sketch, this shed is not part of the facility sketch. While inspecting the shed, LPA observed two cans of paint in the backside of the shed at 8:45am. While continuing the tour of the backyard, LPA observed another shed in the backyard, directly across the previous shed, at 8:45am. LPA observed staff S2 exit the shed, staff S2 stated that was his bedroom. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 71 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms. Fire extinguisher was serviced in July 17, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 24, 2023. Page 1 out of 2. LPA reviewed facility records for 3 staff and 3 residents. LPA requested weight record for residents. ADM stated she used to do weigh the residents, but because they have trouble standing up, she doesn't have a weight record for those residents. The facility did not provide weight records for R1-R3. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R3's medication records, one of R3's medications was two pills short, when cross referencing the medication start date and the Medication administration record. ADM asked S3 what had occurred. S3 stated she did not know. The medication start date was January 17,2024. The MAR showed 10 medications have been administered. And an audit of the medications showed 17 tablets where in the container. ADM could not explain where the two excess pills came from. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2). Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Xi-hua Luo and a copy of the signed report & appeal rights were provided. Page 2 out of 2.the state’s words, verbatim · CDSS document, Jan 27, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Xi-hua Luo . During visit, LPA observed 5 residents and 2 staff. (This report is being amended to add additional information.) LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 6 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. While touring the back yard, at 8:44am, LPA observed a shed, directly across from the sun room. ADM stated this is a staff room, where her staff member sleeps. ADM knocked on the shed, and a staff member with a pink robe exited. LPA interviewed staff S1. S1 stated he/she sleeps in the shed. Based on a review of the facility sketch, this shed is not part of the facility sketch. While inspecting the shed, LPA observed two cans of paint in the backside of the shed at 8:45am. While continuing the tour of the backyard, LPA observed another shed in the backyard, directly across the previous shed, at 8:45am. LPA observed staff S2 exit the shed, staff S2 stated that was his bedroom. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 71 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms. Fire extinguisher was serviced in July 17, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 24, 2023. Page 1 out of 2 LPA reviewed facility records for 3 staff and 3 residents. LPA requested weight record for residents. ADM stated she used to do weigh the residents, but because they have trouble standing up, she doesn't have a weight record for those residents. The facility did not provide weight records for R1-R3. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R3's medication records, one of R3's medications was two pills short, when cross referencing the medication start date and the Medication administration record. ADM asked S3 what had occurred. S3 stated she did not know. The medication start date was January 17,2024. The MAR showed 10 medications have been administered. And an audit of the medications showed 17 tablets where in the container. ADM could not explain where the two excess pills came from. Licensee (LN) Yu Zhang stated that that backyard sheds have locks and have been locked. LN stated the residents don't have access to them. LN stated the backyard sheds are break rooms for staff to take a break as they need. LN stated no resident stays in the sheds. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2). This report was reviewed with Administrator (ADM) Xi-hua Luo . A copy of the report was provided. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 27, 2024