011440427-10-27-2021-15-AS-KHOS-C8DKJ8-20211102075620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011440427
Report Date: 10/27/2021
Date Signed: 10/27/2021 10:27:46 AM

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
03/20/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200320151224

FACILITY NAME:	CHARITYS RESIDENCE		FACILITY NUMBER:	011440427
ADMINISTRATOR:	MARYANN AQUINO LAGURA		FACILITY TYPE:	740
ADDRESS:	2933 MONTEREY BLVD		TELEPHONE:	(510) 482-2855
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94602
CAPACITY:	6	CENSUS: 4	DATE:	10/27/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Caridad Aquino, Licensee		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Staff withheld resident's food.

Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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On 10/27/2021 at 9:50AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to deliver complaint findings for the above allegations.
LPAs met with Caridad Aquino, Licensee, and explained the reason for the visit.

During the course of the investigation, LPAs interviewed staff, one (1) of three (3) residents, obtained and reviewed documents. LPA K. Chow-Yau interviewed Reporting party (RP). LPA reviewed physician’s reports dated 12/5/2018 and 4/2/2020 for Resident 1 (R1) and case notes. Case notes dated 3/18/2020 and 03/30/2020 indicated that R1 had no appetite or refused to eat. Physician’s report date 04/02/2020 indicated diet was vegetarian and soft foods.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200320151224

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: CHARITYS RESIDENCE	FACILITY NUMBER: 011440427
	VISIT DATE: 10/27/2021

NARRATIVE

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Continued from LIC9099.

On the allegation staff handled resident in a rough manner. LPAs interviewed Resident 2 (R2) and staff. R2 has been a resident for 2 years. R2 stated staff has always handled her nicely, and R2 was not aware of staff handling anyone roughly. Staff stated there was one (1) other staff that worked at the facility previously and none of the staff has handled any resident roughly or have seen another staff handle resident in a rough manner.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC9099 (FAS) - (06/04)

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