015601347-5-1-2023-15-AS-KHOS-CRLPVB-20230507113852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601347
Report Date: 05/01/2023
Date Signed: 05/01/2023 12:24:00 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
10/06/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20221006160023

FACILITY NAME:	C & L HOME FOR THE ELDERLY		FACILITY NUMBER:	015601347
ADMINISTRATOR:	GUZMAN, JOSELITO A.		FACILITY TYPE:	740
ADDRESS:	2660 HOP RANCH ROAD		TELEPHONE:	(510) 731-7743
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Vincent Catequista , staff on duty		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility staff do not transfer resident from bed to wheelchair on weekends
Staff does not allow resident to make choices concerning daily life
Staff neglected resident resulting to decline in condition

INVESTIGATION FINDINGS:

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On 5/1/2023 at 10:25AM, Licensing Program Analysts (LPA), L. Ibo arrived unannounced to deliver complaint findings for the above allegations. LPA met with staff Vincent Catequista. LPA explained the reason for the visit. Staff called Administrator via phone, according to Administrator Joselito Guzman, he is not available to meet with LPA.

During the course of investigation, LPA conducted facility tour, records view, staff and residents’ interview.

Allegation: Facility staff do not transfer resident from bed to wheelchair on weekends

Based on staff interview, the staff encouraged or ask resident (R1) to transfer from bed to chair but R1 was the one refusing. Staff claimed that they encouraged resident to be more active but resident (R1) refused. LPA attempted to interview resident (R1), however R1 was not available during the visits.
…Continued to LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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-20221006160023

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: C & L HOME FOR THE ELDERLY	FACILITY NUMBER: 015601347
	VISIT DATE: 05/01/2023

NARRATIVE

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Allegation: Staff does not allow resident to make choices concerning daily life

Based on residents and staff interview. Residents stated that staff let them make their own choices and if staff thinks that those choices is not safe or good decision then staff will let the residents know. Based on staff interview, they claimed that residents can make their choices, but it is their responsibility also to let the residents know what is good and bad for them, the staff claimed they just educate the residents but not interrupt with residents’ choices.

Allegation: Staff neglected resident resulting to decline in condition

Based on residents’ interview, and staff interview. The staff checks the residents at least 2-3X per shift and some residents needs higher level care then staff checks on those residents more often than others. Residents who were interviewed stated that staff checks on them all the time.

LPA observed that residents appeared to be clean, no odor observed and comfortable living at the facility.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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