015601167-2-10-2023-15-AS-KHOS-CPAULH-20230222144045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601167
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:39:19 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
11/19/2021 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20211119084922

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:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Juliana Taburaza, Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Resident had to wait outside due to no staff being at the facility
Resident missed doses of medication
Residents medications were not refilled timely

INVESTIGATION FINDINGS:

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On 2/10/2023 at 1:15PM, 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 caregiver, Marlene Lorincz and informed her the reason for visit. Administrator, Juliana Taburaza arrived an hour later.

During the course of investigation, LPA interviewed 7 residents, 4 staff, witnesses, and complainant. LPA also obtained and reviewed R1's file including: physician's report, IPP, ISP, list of medications, pharmacy refill requests, email correspondence, MAR (Medication Administration Record) for a couple months in 2019, and daily notes.

Resident had to wait outside due to no staff being at the facility
Interview with residents and staff revealed there are staff at the facility to open the door for residents. Staff stated there are at least 2 live-in caregivers at the facility. LPA was unable to obtain additional information on the specific date or time the incident occurred.
(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: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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-20211119084922

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: 02/10/2023

NARRATIVE

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Resident missed doses of medication
LPA reviewed R1's MAR in 2019 and observed R1's medications were either given by staff or documented that R1 was on vacation. There were no missed doses of medications observed in R1's MAR in 2019.

Residents medications were not refilled timely
LPA reviewed email correspondence regarding medication refills and observed Administrator communicated with pharmacy or family for refill when R1 was low on medications. LPA reviewed R1's MAR in 2019 and did not observe any missed doses of medications in 2019.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations 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: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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