011441040-8-30-2023-15-AS-YFLS-CWXRRZ-20231025131558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011441040
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:40:51 PM

Unsubstantiated

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
06/19/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230619150257

FACILITY NAME:	JONES REST HOME		FACILITY NUMBER:	011441040
ADMINISTRATOR:	CHARLES W DRAKE		FACILITY TYPE:	740
ADDRESS:	524 CALLAN AVENUE		TELEPHONE:	(510) 483-6200
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	31	CENSUS: 13	DATE:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Lara Madamba, RCFE Manager		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Neglect- facility was not hydrating the resident
facility staff did not provide documents to responsible person
Facility did not follow care plan- food resident could eat was not given

INVESTIGATION FINDINGS:

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On 8/30/23 at 3:05 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Lara Madamba, RCFE Manager and explained the purpose of the visit.

During the course of the investigation LPA interviewed the reporting party (RP), the facility administrator (ADM) and reviewed documents received from the RP and the facility. R1 lived at the facility from 8/17/2018 until 2/18/2020. Documents received from the facility show that R1’s guardianship was with Alameda County.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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-20230619150257

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: JONES REST HOME	FACILITY NUMBER: 011441040
	VISIT DATE: 08/30/2023

NARRATIVE

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***report continues from LIC9099***

Neglect- facility was not hydrating the resident.

An autopsy was performed on R1 on 11/30/2020. “Reason for autopsy: explanation and cause of death…Confirm malnutrition, dehydration, broken teeth, any evidence of an elderly abuse.” The autopsy revealed no abnormal findings.

Facility staff did not provide documents to responsible person.

During R1’s time at the facility her guardianship was with Alameda County. The guardianship was terminated 1 year after R1’s death. The facility is awaiting instructions from the county as to what, if any, documents the facility can share with the RP.

Facility did not follow care plan- food resident could eat was not given.

Physician’s Report dated 11/20/2019 stated that R1 was on a regular diet with modifications to guard against an adverse reaction due to her colostomy (ie: low fiber). Facility also provided R1 with nutritious snacks throughout the day.

This agency has investigated the complaints alleging: neglect- facility was not hydrating the resident, facility staff did not provide documents to responsible person and facility did not follow care plan- food resident could eat was not given.

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

Exit interview conducted, a copy of this reported provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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