015601122-7-20-2023-15-AS-KHOS-CV5PDJ-20230828111336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601122
Report Date: 07/20/2023
Date Signed: 07/20/2023 10:54:30 AM

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
01/19/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220119154020

FACILITY NAME:	A NEW HAVEN CARE HOME-SPRINGTOWN		FACILITY NUMBER:	015601122
ADMINISTRATOR:	SOLETA, ARNOLD B.		FACILITY TYPE:	740
ADDRESS:	855 CENTRAL AVENUE		TELEPHONE:	(925) 606-7244
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	6	CENSUS: 4	DATE:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Maria "July" Naval, Lead Caregiver		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff do not assist resident(s) with medications as needed.
Staff remove interior door knob(s) to prevent resident(s) from exiting.
Centrally stored medicines are not kept in a safe and locked place.
Night supervision staff are not available to assist in the event of an emergency.

INVESTIGATION FINDINGS:

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On 7/20/2023 at 9:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Lead Caregiver, Maria "July" Naval.

During the course of investigation, LPA interviewed 3 residents and 4 staff. LPA also obtained and reviewed documents including: staff schedule, physician's report, medication list, MAR (Medication Administration Record), and emergency information.

Staff do not assist resident(s) with medications as needed.
Interview with residents revealed that staff would administer medications to residents. Residents stated no medications were missed or not given.
(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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-20220119154020

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: A NEW HAVEN CARE HOME-SPRINGTOWN	FACILITY NUMBER: 015601122
	VISIT DATE: 07/20/2023

NARRATIVE

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Staff remove interior door knob(s) to prevent resident(s) from exiting.
On 1/26/2022, LPA observed front door's door knob was intact with turn lock. Interview with residents indicated the front door was operational without missing door knob.

Centrally stored medicines are not kept in a safe and locked place.
On 1/26/2022, LPA observed medications were locked in the medication cabinet. LPA did not observe unlocked medications on visits dated 1/26/2022 and 7/14/2023.

Night supervision staff are not available to assist in the event of an emergency.
Interview with staff revealed that call button system is wireless and on call night staff will take the wireless system with them to the caregiver's room at night time. There are two live-in staff at the facility. Interview with residents indicated that night staff would assist residents when call button is activated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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