015600756-11-11-2022-15-AS-HHUL-CLDVHC-20221121152656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600756
Report Date: 11/11/2022
Date Signed: 11/11/2022 05:02:30 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
01/04/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210104124530

FACILITY NAME:	ROYAL COLONY VIEW PLACE		FACILITY NUMBER:	015600756
ADMINISTRATOR:	JULIANA TABURAZA		FACILITY TYPE:	740
ADDRESS:	2767 COLONY VIEW PLACE		TELEPHONE:	(510) 889-1288
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	8	CENSUS:	DATE:	11/11/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Leticia Iroy, Caregiver		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to provide assistance in meeting resident's medical needs.

Resident has unusual weight loss.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/11/2022 at 2:00PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Leticia Iroy and explained the reason for the visit. Administrator Juliana Taburaza arrived at 3:35PM.

During the course of the investigation LPA A. Delmundo interviewed staff and Reporting Party (RP). LPA L. Hall obtained and reviewed documents for Resident 1 (R1). On the allegation staff failed to provide assistance in meeting resident's medical needs. The RP stated that on 10/25/2020 it was decided that R1 would have a physical exam conducted. Record review indicated that R1 has a physician's reported dated 11/24/2020 with a follow-up medical appointment dated 4/8/2021.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2022

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-20210104124530

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: ROYAL COLONY VIEW PLACE	FACILITY NUMBER: 015600756
	VISIT DATE: 11/11/2022

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

Continued from LIC9099.

On the allegation Resident has unusual weight loss. RP stated that R1 had an unusual amount of weight loss within six (6) weeks. During record review LPA obtained R1's weight record from January 2020 until November 2022. Records indicated that R1 did have some weight loss between July 2020 and December 2020, and the issue was discussed during the zoom meeting regarding R1. Therefore, the staff did notice the weight loss and followed orders by getting the medical attention needed for R1. Facility staff followed doctor's orders to assist R1 in regaining the weight.

Although the allegations 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 allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2