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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880980
Report Date: 06/13/2026
Date Signed: 06/13/2026 02:03:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
03/08/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240308100814
FACILITY NAME:MAMA ANGELINA COCONOCHOFACILITY NUMBER:
331880980
ADMINISTRATOR:GONZALEZ, MARIA ROSARIOFACILITY TYPE:
740
ADDRESS:862 PIKE DRIVETELEPHONE:
(951) 335-1239
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 6DATE:
06/13/2026
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Crispin Dizon, StaffTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff are not meeting resident's medical needs.
Staff did not contact home health with resident's blood pressure results.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the investigation of the allegations listed above. LPA arrived unannounced and met with Staff, Crispin Dizon. The purpose of the visit was explained.

The investigation consisted of the following:
On 3/15/2024, LPA Yolanda Delgado conducted the initial visit and interviewed staff and a resident. LPA obtained copies of pertinent documentation. LPA Chan interviewed three (3) Staff via telephone on 6/12/26. During the visit today, LPA interviewed one (1) staff, four (4) residents, and a family member.

The investigation revealed the following:
Allegation - Staff are not meeting resident's medical needs. It was alleged that the facility staff was instructed by the home health nurse to check Resident #1’s (R1) blood pressure again in half an hour and give another dose of medication. This incident occurred back in March of 2024.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2026
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 2
Control Number 18-AS-20240308100814
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MAMA ANGELINA COCONOCHO
FACILITY NUMBER: 331880980
VISIT DATE: 06/13/2026
NARRATIVE
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LPA interviewed the administrator and Staff regarding this allegation. The administrator recalled that the home health nurse took the vitals for R1 and noticed the higher blood pressure reading. The nurse informed them to call 911. When the paramedics arrived, R1 refused to go to the hospital. Staff indicated that they were never given any instructions by the home health nurse. Staff continued to monitor R1’s blood pressure throughout the night until the next day. Staff stated that they are always monitoring the residents and will follow any instructions given by the nurses. Staff will communicate with the residents’ responsible party when they need medical attention or notice any changes in the residents. LPA spoke with a family member who stated that they did not request for R1 to receive home health services and stated that she takes R1 to the medical appointments. LPA interviewed four (4) residents. All four residents stated that their families take them to their medical appointments. Staff also communicate with their families when they notice any changes in the residents.

Allegation - Staff did not contact home health with resident's blood pressure results. It is alleged that the staff did not contact the home health nurse regarding Resident #1’s blood pressure reading results. LPA Chan interviewed staff regarding this allegation. Staff indicated that the home health nurse did not provide any instructions to contact the nurse about R1’s blood pressure readings. The home health nurse also did not provide any paperwork regarding the services for R1. Staff stated that when R1’s blood pressure was high, staff was monitoring R1 throughout the night. The next day, R1’s blood pressure became stable. Staff interviewed stated that they communicate with the home health or hospice nurses if they notice any changes in the resident. Based on information gathered, there is insufficient evidence to corroborate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2026
LIC9099 (FAS) - (06/04)
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