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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600526
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:23:02 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
10/15/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20241015103505
FACILITY NAME:ELDERS INN ON WEBSTERFACILITY NUMBER:
015600526
ADMINISTRATOR:MARIE ANN LAGASCAFACILITY TYPE:
740
ADDRESS:1721 WEBSTER STREETTELEPHONE:
(510) 521-9200
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:60CENSUS: 40DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rolinda Noquillo, AdministratorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Uncleared staff providing care to residents
INVESTIGATION FINDINGS:
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On 10/24/24 at 2:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegation above. LPA met with Rolinda Noquillo, Administrator and explained the purpose of the visit.

During the investigation it was determined that S2 does not have fingerprint clearance.

During the visit Licensee called S2 told him not to report to work. S2 is not to return to the facility until his background exemption has been granted.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted, a copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 2
Control Number 15-AS-20241015103505
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: ELDERS INN ON WEBSTER
FACILITY NUMBER: 015600526
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
87355(d)(3)
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) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... (3) The licensee shall submit these fingerprints... for the purpose of searching the records... prior to the individual's employment, residence, or initial presence in the facility. This requirement was not met as evidence by:
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S2 was called and told not to report to work. S2 will remain off work until appeal is granted.
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Based on record review the Licensee did not comply with the section cited above. S2 was not fingerprinted before working at facility which poses a potential immediate health and safety risk to 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
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