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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601284
Report Date: 08/24/2020
Date Signed: 08/24/2020 10:11:36 AM



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
05/01/2020 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200501114249
FACILITY NAME:RAKSHA 6FACILITY NUMBER:
015601284
ADMINISTRATOR:BHUTANI, NALANIFACILITY TYPE:
740
ADDRESS:1133 GARFIELD AVENUETELEPHONE:
(510) 558-7241
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:6CENSUS: 3DATE:
08/24/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shalini Bhutani, AdministratorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility staff is not providing a comfortable environment for resident
INVESTIGATION FINDINGS:
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On 08/24/2020, Licensing Program Analyst (LPA) T. White called the facility to deliver the complaint findings for the above allegation. LPA spoke with Administrator, Shalini Bhutani. LPA explained due to the present shelter in place order by the Governor, the notification of the complaint is being done over the phone.

During the course of investigation, LPA conducted interviews and collected documentation in relation to the complaint. Based on information provided, facility was informed verbally and via notes by Resident #1 (R1) Occupational Therapist to restrict R1 from sitting in the recliner because of R1’s neck brace causing headaches. The facility did go over with R1 the need to limit prolonged use of recliner, but R1 wanted to remain in recliner.

Report continues on 9099C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2020
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 2
Control Number 15-AS-20200501114249
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: RAKSHA 6
FACILITY NUMBER: 015601284
VISIT DATE: 08/24/2020
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator and a copy of report emailed to facility.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2