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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601270
Report Date: 11/05/2021
Date Signed: 11/05/2021 05:09:14 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
03/30/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200330131123
FACILITY NAME:A GABRIELA'S VILLA-LIVERMOREFACILITY NUMBER:
015601270
ADMINISTRATOR:TRINIDAD, DUMITELA A.FACILITY TYPE:
740
ADDRESS:1051 LYNN STREETTELEPHONE:
(925) 998-4316
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dumitela Trinidad (Dimapilis), LicenseeTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Not following physicans orders
Reporting requirements
INVESTIGATION FINDINGS:
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On 11/5/2021 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegations above. LPA met with Licensee, Dumitela Trinidad.

During the investigation, LPA interviewed 3 staff and reviewed R1's file including list of medications, MAR, discharge documents, and incident reports.

R1 did not have a doctor's order for iron supplement. However, LPA observed R1 was prescribed hydrocortisone cream by doctor. R1's cream was not documented on MAR. Interview with staff indicated that R1 refused to use the cream. Staff did not note refusal of cream in the MAR or care notes. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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 4
Control Number 15-AS-20200330131123
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 GABRIELA'S VILLA-LIVERMORE
FACILITY NUMBER: 015601270
VISIT DATE: 11/05/2021
NARRATIVE
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LPA reviewed incident reports received by RO and observed no incident report was received from January 2020 through May 2020 for R1. LPA observed that R1 was sent to ER in January 2020, but did not receive an incident report from licensee. Interview with staff indicated that incident report was not sent to RO.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20200330131123
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 GABRIELA'S VILLA-LIVERMORE
FACILITY NUMBER: 015601270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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Licensee has agreed to train all staff medication administration and record keeping. Licensee will submit staff sign in sheet and training material to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not administering cream to R1 which poses a potential health and safety risk to the residents in care.
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Type B
11/19/2021
Section Cited
CCR
87211(a)(1)
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Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement was not met as evidence by:
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Licensee has agreed to review reporting requirements and submit self-certification to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not submitting incident report to CCLD which poses a potential health and safety risk to the residents 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
03/30/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200330131123

FACILITY NAME:A GABRIELA'S VILLA-LIVERMOREFACILITY NUMBER:
015601270
ADMINISTRATOR:TRINIDAD, DUMITELA A.FACILITY TYPE:
740
ADDRESS:1051 LYNN STREETTELEPHONE:
(925) 998-4316
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dumitela Trinidad (Dimapilis), LicenseeTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Lack of seeking medical treatment
INVESTIGATION FINDINGS:
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On 11/5/2021 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegation above. LPA met with Licensee, Dumitela Trinidad.

During the investigation, LPA interviewed 3 staff and reviewed R1's file including list of medications, MAR, and discharge documents. Records indicated that R1 was discharged from hospital in January 2020 and facility was in communication with R1's doctor. Interview with staff indicated that R1 was taken to the doctors and hospital by S1.

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

Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4