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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011405931
Report Date: 04/15/2021
Date Signed: 04/15/2021 03:59:46 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2020 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200205145532
FACILITY NAME:FLORENCE RESIDENTIAL CARE HOME IFACILITY NUMBER:
011405931
ADMINISTRATOR:RIVAC, A. WARLITAFACILITY TYPE:
740
ADDRESS:1954 ROSEMARY COURTTELEPHONE:
(510) 490-1801
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:0CENSUS: 0DATE:
04/15/2021
UNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Licensee, Warlita RivacTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained multiple falls while in care
Staff failed to properly report incidents regarding a resident
Staff mishandling resident's personal hygiene products
INVESTIGATION FINDINGS:
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On 04/15/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an announced visit with Licensee Warlita Rivac to deliver investigative findings on the above allegations. Due to State's current shelter in place order pertaining to COVID-19 it was not possible to perform this visit at the facility. The visit was performed by telephone.

During the course of the investigation LPA Yvonne Flores-Larios toured facility building and grounds, interviewed staff and witnesses, and obtained relevant documentation from facility and reporting party. Based on information obtained, R2's family member provided facility 300 diapers on December 13, 2019 and another 300 diapers were requested from administrator on January 24, 2020, R2 was hospitalized on January 26, 2020. R2’s family requested the remainder of diapers and only 200 were returned. R2’s family reminded administrator that R2 was only at the facility for two days, administrator then took R2’s
Continued on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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 15-AS-20200205145532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FLORENCE RESIDENTIAL CARE HOME I
FACILITY NUMBER: 011405931
VISIT DATE: 04/15/2021
NARRATIVE
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family to the garage where there were hundreds of diapers stored.

During physical plant tour LPA observed 25 boxes of under pads/diapers in the garage and additional incontinence supplies in several bedroom closets. Based on record review R1 and R2 both required incontinent care. However, R1 had only recently began incontinence care during the time of physical tour on 2/10/2020 due to decline in health. It was stated by R1’s family that facility provided all the incontinent supplies and they have never been asked to order any incontinent care supplies by facility which contradicts statements from staff that resident’s family were supplying incontinent care items.

LPA reviewed facility file for any incident reports regarding falls for R1 and R2. There were no such reports ever made to CCLD. However, hospital records received indicate R2 sustained multiple falls while in care at the facility and indicated R2 was a fall risk.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20200205145532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FLORENCE RESIDENTIAL CARE HOME I
FACILITY NUMBER: 011405931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2021
Section Cited
CCR
82711(a)
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82711 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement was
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By POC date administrator agrees to review regulation and send a copy of self-certification letter to CCLD.
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not met as evidenced by; Based on LPA interviews and records reviewed facility did not comply with the above regulation. No incident reports were submitted to CCLD for falls that R2 sustained while in care at the facility which poses a potential health and safety risk to residents in care.
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Type B
04/22/2021
Section Cited
CCR
87486.1(a)(12)
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87486.1 Personal Rights of Residents in All Facilities (a)...shall have all of the following personal rights: (12)... to keep and use their
own personal possessions, including their toilet articles... This
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By POC date administrator agrees to review regulation and send a copy of self-certification letter to CCLD.
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requirement was not met as evidenced by: Based on LPA physical plant tour and interviews conducted licensee did not comply with the above regulations as cited. LPA observed boxes of incontinent care supply throughout the garage and home that R2 had supplied to the facility for R2 needs. R1’s family stated that the facility provides incontinent care supplies which does not match staff’s statement that residents provide incontinent supplies. This poses a potential personal rights 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2020 and conducted by Evaluator Allison O'Hollaren
COMPLAINT CONTROL NUMBER: 15-AS-20200205145532

FACILITY NAME:FLORENCE RESIDENTIAL CARE HOME IFACILITY NUMBER:
011405931
ADMINISTRATOR:RIVAC, A. WARLITAFACILITY TYPE:
740
ADDRESS:1954 ROSEMARY COURTTELEPHONE:
(510) 490-1801
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:0CENSUS: 0DATE:
04/15/2021
UNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Licensee, Warlita RivacTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff unable to manage resident's urinary catheter
INVESTIGATION FINDINGS:
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On 04/15/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an announced visit with Licensee Warlita Rivac to deliver investigative findings on the above allegations. Due to State's current shelter in place order pertaining to COVID-19 it was not possible to perform this visit at the facility. The visit was performed by telephone.

During the course of the investigation LPA Yvonne Flores-Larios toured facility building and grounds, interviewed staff and witnesses, and obtained relevant documentation from facility and reporting party. During interviews conducted with staff, staff were unable to recall if R2 had a urinary catheter but did acknowledge that R2 was using diapers. Documentation received from facility records of R2 did not indicate whether a urinary catheter was in place and LPA received two different pre-placement appraisals for R2 with same date of 11/11/2016 indicating that R2 did not require any incontinent care. LPA
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20200205145532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FLORENCE RESIDENTIAL CARE HOME I
FACILITY NUMBER: 011405931
VISIT DATE: 04/15/2021
NARRATIVE
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was not able to obtain any current information in regard to incontinent care or catheter from facility records. LPA did obtain hospital documentation for R2 dated 1/24/2020 that stated R2 required extensive assistance with bowel control and total dependence with bladder control. In same documentation it is stated that R2 was placed with a catheter.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20200205145532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FLORENCE RESIDENTIAL CARE HOME I
FACILITY NUMBER: 011405931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2021
Section Cited
CCR
87466
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87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation
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By POC date administrator agrees to review regulation and send a copy of self-certification letter to CCLD.
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reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by; Based on interviews and records reviewed licensee did not comply with the above regulations as cited. Licensee had no documentation to support changes in R2 condition that may have occurred during the resident’s stay at the facility, with poses a potential health and safety 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6