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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701473
Report Date: 09/10/2026
Date Signed: 09/10/2026 03:50:52 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
12/08/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251208143528
FACILITY NAME:AN ANGEL GARDEN IIFACILITY NUMBER:
342701473
ADMINISTRATOR:CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:10213 SUTARA WAYTELEPHONE:
(530) 280-8495
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
09/10/2026
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Youngsuk ChoTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication
Staff are not meeting resident's diapering needs
INVESTIGATION FINDINGS:
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On 09/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Administrator Youngsuk Cho and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 5. A brief interview was conducted with Administrator Cho.

It was alleged that staff are mismanaging resident’s medication. The investigation consisted of observations, record reviews, and interviews with facility staff, outside agencies, and the resident’s responsible party. During a facility visit on 07/10/2026, LPA Lee conducted a medication audit for all five residents in care and identified medication discrepancies involving four of the five residents. LPA Lee observed five medications that had been pre-poured for the evening medication pass.

CONTINUED LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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 6
Control Number 27-AS-20251208143528
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 II
FACILITY NUMBER: 342701473
VISIT DATE: 09/10/2026
NARRATIVE
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Administrator Cho stated that a hospice social worker observed the practice and advised staff that double briefing was inappropriate and could be considered neglect. Administrator Cho reported that the facility immediately discontinued the practice. A review of R1’s LIC 625, Appraisal/Needs and Services Plan, did not identify double briefing as part of R1’s required incontinence care. Based on interviews and records reviewed, the allegation that facility staff are not meeting residents incontinence needs is SUBSTANTIATED.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Administrator Cho and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

An exit interview was conducted with Administrator Cho and the LIC 9099 report was provided to the facility at the end of the visit.


SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20251208143528
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 II
FACILITY NUMBER: 342701473
VISIT DATE: 09/10/2026
NARRATIVE
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LPA Lee also observed four small Ziploc bags containing multiple medications taped to the medication cabinet. The Administrator stated that she had prepared the bags as medication samples to guide staff in administering residents’ medications while she was out of state in December 2025. LPA Lee further observed that resident 2’s (R2’s) Medication Administration Record (MAR) had been initialed through 07/30/2026 before the medications were administered. A review of resident 1’s (R1’s) November 2025 MAR showed that Senna 8.6 mg was prescribed to be administered at bedtime but was not administered from 11/01/2025 through 11/30/2025. The MAR documented that Senna was held from 11/01/2025 through 11/10/2025 due to lose or watery bowel movements and from 11/11/2025 through 11/29/2025 due to a coccyx wound. The hospice order permitted staff to hold Senna when R1 experienced loose stools; however, there was no physician’s order authorizing staff to hold the medication due to R1’s coccyx wound. R1’s December 2025 MAR showed that Senna was held from 12/01/2025 through 12/04/2025 and administered on 12/05/2025. The MAR again documented that the medication was held due to R1’s coccyx wound, although there was no physician’s order authorizing Senna to be held for that reason. In a letter sent to LPA Valerio on 12/16/2025 at 12:55 p.m., Administrator Cho stated that staff observed persistent watery bowel movements and worsening of R1’s coccyx wound. Due to these symptoms, Senna was placed on hold beginning 10/27/2025 and remained on hold. However, there was no physician’s order authorizing staff to hold the medication due to the coccyx wound. Based on observations, interviews, and records reviewed, the facility pre-poured residents’ medications, used unsecured medications as samples, initialed MARs before medications were administered, failed to maintain complete and accurate medication records, and withheld medication for a reason not authorized by the physician’s order. Therefore, the allegation that facility staff mismanaged residents’ medications is SUBSTANTIATED. A preponderance of the evidence establishes that the alleged violation occurred.

It was alleged that facility staff are not meeting residents incontinence needs. The investigation consisted of interviews with facility staff, outside agencies, and resident’s responsible party, as well as a review of relevant records. LPA Lee received an email from Administrator Cho on 08/24/2026 at 2:17 PM she acknowledged that staff placed two incontinence briefs on R1 after leakage occurred the previous day, while R1 was seated in a wheelchair.

PAGE 2 CONTINUED LIC 9099-C

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
12/08/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251208143528

FACILITY NAME:AN ANGEL GARDEN IIFACILITY NUMBER:
342701473
ADMINISTRATOR:CHO, YOUNGSUKFACILITY TYPE:
740
ADDRESS:10213 SUTARA WAYTELEPHONE:
(530) 280-8495
CITY:ELK GROVESTATE:CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
09/10/2026
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Youngsuk ChoTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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staff are overdosing resident
Staff are not using a two person assist for resident resulting in injuries
INVESTIGATION FINDINGS:
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On 09/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Administrator Youngsuk Cho and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 5. A brief interview was conducted with Administrator Cho.

It was alleged that staff overdosed resident. The investigation consisted of record reviews, and interviews with facility staff, outside agencies, and resident’s responsible party. LPA Lee reviewed R1’s medication records for the prescribed PRN Lorazepam. According to R1’s Medication Administration Records (MARs), R1 received Lorazepam 11 times in November 2025 and four times in December 2025. Administrator Cho denied the allegation and stated that Lorazepam was prescribed to R1 on an as-needed basis.

CONTINUED LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20251208143528
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 II
FACILITY NUMBER: 342701473
VISIT DATE: 09/10/2026
NARRATIVE
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 The evidence reviewed did not establish that staff administered Lorazepam in excess of the physician’s order or otherwise overdosed R1. Therefore, the allegation that staff overdosed resident is UNSUBSTANTIATED.

It was alleged that staff are not using a two-person assist for resident resulting in injuries. The investigation consisted of record reviews and interviews with facility staff, outside agencies, and two residents ’responsible parties. During a facility visit on 12/12/2025, LPA Valerio observed two staff members present with three residents in care. During another visit on 07/10/2026, LPA Lee observed three staff members present with five residents in care. During today’s visit, LPA Lee observed two facility staff with five residents in care. Facility staff denied the allegation and stated that at least two staff members are present at the facility at all times. One resident’s responsible party reported consistently observing two to three staff members during their visits and expressed no concerns regarding staffing. LPA Lee reviewed the facility’s LIC 500 Personnel Report, which indicated that two staff members were scheduled during each shift. R1’s LIC 625 Appraisal/Needs and Services Plan indicated that R1 required two-person assistance with transfers, showering, and toileting. However, the records reviewed did not show that R1 sustained hematomas or other injuries to R1’s arms or legs due to staff not providing the required assistance. Based on the interviews and records reviewed, there was insufficient evidence to establish that staff are not providing two person assist for the resident resulting in injuries; therefore, the allegation is UNSUBSTANTIATED.

The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation 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 violation occurred.

An exit interview was conducted with Administrator Cho and the LIC 9099 report was provided to the facility at the end of the visit.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20251208143528
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 II
FACILITY NUMBER: 342701473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2026
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement was not met as evidence by:
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Administrator agrees to complete incidental medical services in-service training for all staff, including training on the five rights of medication administration.
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Based on observation and file review, the Licensee did not ensure R1 was being administer their senna medication. This posed a potential health and safety risk to R1.
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 The facility will submit the training materials, staff sign-in sheet, and a signed statement confirming that staff have read and understand the applicable regulation. POC is due by 5:00 p.m. on 09/24/2026.
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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.
SUPERVISOR'S NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6