015601283-4-22-2021-15-AS-KHOS-C2GJQ6-20210427071438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601283
Report Date: 04/22/2021
Date Signed: 04/22/2021 05:05:49 PM

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
08/01/2019 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20190801154049

FACILITY NAME:	PARKVIEW, THE		FACILITY NUMBER:	015601283
ADMINISTRATOR:	ZAININGER, SYLVIA		FACILITY TYPE:	740
ADDRESS:	100 VALLEY AVE		TELEPHONE:	(925) 461-3042
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY:	123	CENSUS: 84	DATE:	04/22/2021
		UNANNOUNCED	TIME BEGAN:	04:20 PM
MET WITH:	Aireen Tibon/Executive Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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-Staff makes inappropriate comments to the residents.

INVESTIGATION FINDINGS:

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On this day, April 22, 2021, Licensing Program Analyst (LPA) Delmundo called and spoke with Executive Director Aireen Tibon to deliver the findings on the above allegation. LPA informed that due to management directive to telework, LPA is delivering the findings via televisit.

It was alleged that staff (S1) made inappropriate comments to resident (R1) such as referencing the size of R1’s private parts and responding rudely to residents when asked for assistance.

During the course of investigation, LPA interviewed staff (S1, S2, S3, S4, S5, S6 and S7) and R1’s family member (FM). S1 denied being rude or referenced resident’s private parts. Four (4) out of the 6 other staff interviewed stated that S1 is either rude to residents, handled resident (R1) roughly and/or complained/questioned residents when residents pushed the call button for assistance. FM stated that although she didn’t hear S1 referenced R1’s private part, she personally observed S1 responding inappropriately to R1.
.....continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

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 5

Control Number 15-AS-20190801154049

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: PARKVIEW, THE	FACILITY NUMBER: 015601283
	VISIT DATE: 04/22/2021

NARRATIVE

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Based on information obtained, allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalties.

Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided via e-mail to Aireen Tibon.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20190801154049

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: PARKVIEW, THE	FACILITY NUMBER: 015601283
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/29/2021 Section Cited CCR 87468.1(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive director to conduct in-service training and submit copy of the training with attendees’ signatures by 4/29/2021.
	8 9 10 11 12 13 14	-Based on interviews, licensee did not comply with the above Regulation. S1 responded inappropriately to residents when called for assistance which posed potential personal rights risks to person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
08/01/2019 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20190801154049

FACILITY NAME:	PARKVIEW, THE		FACILITY NUMBER:	015601283
ADMINISTRATOR:	ZAININGER, SYLVIA		FACILITY TYPE:	740
ADDRESS:	100 VALLEY AVE		TELEPHONE:	(925) 461-3042
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY:	123	CENSUS: 84	DATE:	04/22/2021
		UNANNOUNCED	TIME BEGAN:	04:20 PM
MET WITH:	Aireen Tibon/Executive Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff fails to meet the resident's (R1) needs.

INVESTIGATION FINDINGS:

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On this day, April , 2021, Licensing Program Analyst (LPA) Delmundo called and spoke with with Executive Director Aireen Tibon to deliver the findings on the above allegation. LPA informed that due to management directive to telework, LPA is delivering the findings via televisit.

It was alleged that S1 is not providing water and blanket when R1 requested and gives the beverage in the tray in R1’s room that maybe old and warm. It is also alleged that S1 positions the mechanism to adjust the bed’s height away from R1’s reach.

...........continued next page (LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

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 5

Control Number 15-AS-20190801154049

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: PARKVIEW, THE	FACILITY NUMBER: 015601283
	VISIT DATE: 04/22/2021

NARRATIVE

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LPA interviewed staff (S1, S2, S3, S4, S5, S6 and S7) and R1’s family member (FM). S1 denied putting R1’s bed’s mechanism away from R1’s reach. Only 1 out of the other 6 staff indicated S1 put the mechanism on the floor. One of the 6 staff said that she observed R1’s bed high which caregiver may have raised when R1 was changed. FM indicated that although she did not observe the mechanism in adjusting the bed’s height away from R1, she observed the tv remote control and the phone away from R1’s reach.

Based on information gathered, allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Copy of this report provided via e-mail to Aireen Tibon.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5