015600255-12-28-2022-15-AS-YFLS-CMLU2Y-20221230141242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600255
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:08:18 PM

Unfounded

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
10/12/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20221012083441

FACILITY NAME:	MERCY RETIREMENT & CARE CENTER		FACILITY NUMBER:	015600255
ADMINISTRATOR:	ADRIAN JOHN CRUZ, JR.		FACILITY TYPE:	741
ADDRESS:	3431 FOOTHILL BOULEVARD		TELEPHONE:	(510) 534-8540
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	160	CENSUS: 68	DATE:	12/28/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	John Cruz, ED		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff denied resident visitors

INVESTIGATION FINDINGS:

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On 12/28/2022 at 2:45 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegation. LPA met with John Cruz, Executive Director and explained the purpose of the visit.

During the course of investigation LPA interviewed the complainant (RP), facility administrator (ADM) and R1. LPA also reviewed the facility’s visitor policy and R1’s weekly visitor schedule.

RP’s interview confirmed that she is not being allowed to visit R1 when she arrives at the facility. RP also reported to LPA that she has tried several times to contact the individual who schedules R1’s visitors but has not heard back for over 6 months.

Report continues on LIC9099C

Unfounded

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: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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-20221012083441

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: MERCY RETIREMENT & CARE CENTER	FACILITY NUMBER: 015600255
	VISIT DATE: 12/28/2022

NARRATIVE

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***Report continues from LIC9099***

LPA interviewed ADM. ADM stated that facility residents are allowed visitors per the facility’s visitor policy. ADM also stated that R1 has a friend who sets R1’s visitor schedules in consultation with R1 and provide it to the facility every week. ADM also stated that R1 has expressed that he does not wish to have visits from the RP.

LPA interviewed R1 who said he enjoys living at the facility and receiving visitors. R1 confirmed that he has a friend who schedules his visitors on a weekly basis. When LPA asked if R1 would like to have visits with the RP he shook his head no and waved his hands in the air. R1 then stated that he asked his friend who does his visitors schedule to “take care of it.”

This agency has investigated the complaint alleging that facility staff denied visitors. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC9099 (FAS) - (06/04)

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