015601425-5-29-2024-15-AS-YFLS-D6522Q-20240610170107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601425
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:54:31 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
05/23/2024 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240523143714

FACILITY NAME:	HEATHER'S CARE HOME		FACILITY NUMBER:	015601425
ADMINISTRATOR:	VEGA-CAJUCOM, MICHELLE M		FACILITY TYPE:	740
ADDRESS:	3279 LANGHORN DRIVE		TELEPHONE:	(510) 648-2461
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY:	6	CENSUS: 6	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jonas Depasupil		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Staff are not properly cleaning resident after bowel movements
Staff are double diapering resident

INVESTIGATION FINDINGS:

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On this day at around 2PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct investigation on the above allegations and met with Administrator Jonas Depasupil and Michelle Vega-Cajucom. LPA explained to both Administrators the purpose of the visit.

During the visit, LPA interviewed both Administrators. LPA obtained the following records for Client 1 (C1): IPP, Physician's Report, Medication Administration Record (MAR), doctor's order and email correspondence between day program and facility.

Based on C1's Physician's Report dated 3/1/2024, C1 is incontinent for both bladder and bowel. C1 experiences occasional bowel/bladder incontinence. A review of C1's MAR indicates that C1 is on Miralax on a daily basis and takes Hydrochlorothiazide 2x a day.

continuation on Lic 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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-20240523143714

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: HEATHER'S CARE HOME	FACILITY NUMBER: 015601425
	VISIT DATE: 05/29/2024

NARRATIVE

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continuation from Lic 9099

S2 states that the Miralax has been very effective in preventing C1 from getting constipated and the Hydrochlorothiazide in stabilizing C1's blood pressure.

Both Administrators state that C1 has been using a diaper and a chucks pad since C1 came back to the program after the pandemic due to C1's occasional incontinence. The chucks pad is an extra protection in case C1 gets a bowel/urine accident while on transit. They both state that C1 gets cleaned thoroughly and goes to the bathroom at least 30 minutes before C1 gets picked up by the transportation. And that C1 takes a shower every morning.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiency is noted for this visit.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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