015601167-2-8-2023-15-AS-KHOS-CP4NPE-20230216093813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601167
Report Date: 02/08/2023
Date Signed: 02/08/2023 01:29:36 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
07/28/2021 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20210728150739

FACILITY NAME:	PALM TREE COURTYARD		FACILITY NUMBER:	015601167
ADMINISTRATOR:	JULIANA TABURAZA		FACILITY TYPE:	740
ADDRESS:	550 DEAN STREET		TELEPHONE:	(510) 538-7428
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	15	CENSUS: 10	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Juliana Taburaza, Administrator/Licensee		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff hits residents in care
Staff yells at residents in care
Staff did not assist resident with medication
Staff refused to provide drinking water to resident

INVESTIGATION FINDINGS:

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On 2/8/23 at 12:50 p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Juliana Taburaza, administrator/ licensee and explained the purpose of the visit.

Allegations: Staff hits residents in care and Staff yells at residents in care

On 8/05/2021 LPA interviewed S1, S2, and S3 states “they never hit any residents nor yell at any resident.” LPA interviewed R2, and R3 regarding any staff hits or yell at R2. R2 reply “They treat me good”. Did somebody hit you? R2 reply “No”. Have R2 ever seen staff hit other residents: R2 Reply “Oh no, no”. R3 reply “staff has never hit me”.

Report continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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-20210728150739

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: PALM TREE COURTYARD	FACILITY NUMBER: 015601167
	VISIT DATE: 02/08/2023

NARRATIVE

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Allegation: Staff did not assist resident with medication

On 8/05/21 LPA reviewed resident’s medication records (MAR) shown that staff are assisting resident with medication. MAR records shown that medication is given as prescribed by the doctor.

Allegation: Staff refused to provide drinking water to resident

On 8/05/21 LPA interviewed S1, S2, and S3 all states that they were not refusing to give any residents water when residents asked. LPA interviewed R1, R2, and R3 all states staffs gives them water when they asked, but some residents decided to get water themselves.

Based upon records review, interviews conducted, and observations made, the Department has investigated the above allegations and found that they are Unsubstantiated. A finding that the complaint allegation/s are Unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

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