015600148-1-12-2023-15-AS-HHUL-CP5N7P-20230217091305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600148
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:53:03 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
06/17/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220617090922

FACILITY NAME:	ROSEGATE		FACILITY NUMBER:	015600148
ADMINISTRATOR:	LEUNG, BELINDA		FACILITY TYPE:	740
ADDRESS:	1345 CLARKE STREET		TELEPHONE:	(510) 483-0150
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	40	CENSUS: 32	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Irene DeLeon, facility manager and Jeffrey Tong, backup administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Questionable deaths

INVESTIGATION FINDINGS:

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On 01/12/2023, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings for the above allegation. LPA met with Irene DeLeon, facility manager and Jeffrey Tong, backup administrator, LPA explained the purpose of the visit. Administrator Belinda Leung is not available during the visit.

During course of the investigation, the Department conducted interviews with facility staff, witnesses and complainant. Documents including but not limited to: R1’s, R2’s & R3’s admission agreement, physician’s reports, medication log, hospice report, incident report, death certificate, hospice notes and medication order.

Continued to LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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-20220617090922

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: ROSEGATE	FACILITY NUMBER: 015600148
	VISIT DATE: 01/12/2023

NARRATIVE

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Based on information obtained, R1, R2 & R3’s death certificate indicated that three residents died of natural cause. The Department received records indicating R1 & R3 was receiving hospice care under Suncrest Hospice and R2 was receiving hospice under Pathways Hospice. Based on records review R1, R2 & R3 received medications as prescribed by doctors, no suspected neglected or abuse observed.

Based on records review, on 12/1/2021 R1 was admitted on hospice and passed away on 6/10/2022 with caused of death of vascular dementia.

Based on records review, on 1/3/2022 R2 was transferred to Suncrest hospice. Records review revealed that on 6/1/2022, 6/2/2022 ,6/3/2022 and 6/4/2022, there was no indication of administering morphine. On 6/10/2022, R2 passed away with caused of death of Alzheimer’s.

Based on records review, on 5/23/2022 R3 was admitted under Suncrest Hospice. On 6/8/2022, R3 passed away with caused of death of Senile dementia of the nervous system.

This agency has investigated the complaint. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Jeffrey Tong and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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