<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600386
Report Date: 06/06/2024
Date Signed: 06/06/2024 11:37:51 AM

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
05/31/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240531103645
FACILITY NAME:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR:PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
06/06/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jezrael Pascual, Facility ManagerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator is not at the facility a sufficient amount of time to manage the daily operations
Staff do not follow reporting requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at around 8:45 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct investigation on the above allegations. LPA met with facility manager Jezrael Pascual and explained the purpose of visit. LPA informed Administrator (AD), Victoria Puruganan the purpose of visit over the phone. Administrator was unavailable and gave verbal permission to facility staff to sign the report.

Allegation: Administrator is not at the facility a sufficient amount of time to manage the daily operations: Substantiated
During the course of investigation, LPA interviewed S1, and S2 indicated Administrator is not at the facility a sufficient amount of time to manage daily operations. S1 stated that AD gave full trust to an individual staff that AD was assuming that everything was under control; therefore, AD do not need to come often. S2 admitted that S2 was not as the facility as often were S2 supposed to be to handle daily operation.

Report continue on LIC 9099c...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
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-20240531103645
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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386
VISIT DATE: 06/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff do not follow reporting requirements: Substantiated

Based on interview conducted S1 and S2 indicated that some reports are no being reported to CCLD, due to S2 assuming that the Individual staff are doing the reporting. According to S1 times that incident happened but the staff that are put in charge did not report, and AD is assuming that the report had been made.

Based on LPA interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22. Deficiencies are being cited on the attached LIC 9099D.

LPA discuss plan of correction to AD, and AD agree to the finding of the allegation over the phone.

Exit interview was conducted with facility manager. A report and appeal rights was provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240531103645
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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... This requirement is not
1
2
3
4
5
6
7
Licensee/ Administrator agrees to have a set hour dedicated at the facility to handle daily administrator daily operation. Licensee/ Administrator agrees to review the regulation under Administrator qualification and submitted a self-certified letter confirm that licensee/ administrator understanding of the regulation and fax it to CCLD by POC date.
8
9
10
11
12
13
14
Based on inteviews, the licensee did not comply with the section cited above by not having the administrator at the facility for a sufficient number of hours which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Administrator will review and conduct an in service training on Reporting Requirements and fax a copy of the training agenda to CCL by POC date.
Type B
06/14/2024
Section Cited
CCR
87211(a)
1
2
3
4
5
6
7
87211(a) REPORTING REQUIREMENTS
Each licensee shall furnish to the licensing agency such reports as the Department may require..

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Based on intervews conducted licensee/adminisrator did not comply with the section cited above by not not follow reporting requirements which poses an immediate health and safety risk to persons in care
8
9
10
11
12
13
14
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: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3