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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011440744
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:16:37 PM

Substantiated


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
10/10/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20231010160613
FACILITY NAME:GEORGE'S HOME CARE IIFACILITY NUMBER:
011440744
ADMINISTRATOR:VIDICAN, GEORGEFACILITY TYPE:
735
ADDRESS:547 CHERRY WAYTELEPHONE:
(510) 481-8871
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 2DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:George Vidican/Licensee-administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility does not have adequate staffing to care and supervise residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with George Vidican, licensee-administrator, and informed the reason for visit.

It was alleged that that the administrator hurt his back recently and currently receiving physical therapy. It has been known that the administrator is the full time staff but since he hurt his back, he is unable to do his duties and resident (R2) is assisting the administrator in helping push the other resident (R1) who is in wheelchair.

LPA interviewed R1 and R2's case managers; one stated that the administrator told the case manager that R2 is helping push the wheelchair, and the other case manager stated observing in person last week the administrator using cane while resident's responsible person pushed R1 who is in wheelchair.

....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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 3
Control Number 15-AS-20231010160613
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: GEORGE'S HOME CARE II
FACILITY NUMBER: 011440744
VISIT DATE: 10/18/2023
NARRATIVE
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During today's visit, LPA observed canes in the 2 buildings and administrator stated he uses cane from time to time and that he is still undergoing physical therapy. LPA further learned from administrator that R2 assists in pushing R1 when in wheelchair.

Based on information gathered, the preponderance of evidence is met, therefore the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20231010160613
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: GEORGE'S HOME CARE II
FACILITY NUMBER: 011440744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
80065(a)
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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
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Admininstrator stated he'll have the back-up staff come on board in providing care and supervision to residents. Copy of LIC500 Personnel Report to be submitted by 11/01/23.
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-This requirement is not met as evidenced by:

-Based on interviews, the licensee did not comply with the section above for a resident assisting in pushing another resident in wheelchair which poses potential safety and/or personal rights risks of persons 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3