015601469-9-21-2022-15-AS-KHOS-CJVHXC-20221004063455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601469
Report Date: 09/21/2022
Date Signed: 09/21/2022 07:17:06 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
09/16/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220916112619

FACILITY NAME:	LOVING HOME CARE		FACILITY NUMBER:	015601469
ADMINISTRATOR:	GOLDASSIO, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	22270 PERALTA STREET		TELEPHONE:	(510) 582-8839
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	5	CENSUS: 2	DATE:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Matilde Miguel Machado/Licensee and Robert Goldassio/Operations Manager		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Hygiene item was accessible to resident (R1).

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Matilde Miguel Machado, licensee, and Robert Goldassio, operations manager. LPA also met with Stephanie Goldassio, administrator. LPA informed the purpose of visit.

LPA reviewed resident's record including but not limited to LIC602A Physician's Report and Admission Agreement. LPA conducted interviews.

LPA received Unusual Incident Report (UIR) from Robert Goldassio for R1 pertaining to the incident that occured on September 14, 2022 when R1 sustained cuts on the fingers by using an electric shaver. Staff interviewed stated that R1's electric shaver was in R1's room. Review of records showed R1 has dementia.

......continued next page (9099C).

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: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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-20220916112619

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: LOVING HOME CARE	FACILITY NUMBER: 015601469
	VISIT DATE: 09/21/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the information obtained, the allegation of hygiene item was accessible to resident (R1) is closed as 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 and listed on 9099D. A $500.00 civil penalty is assessed on this day. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency, plan and proof of correction and civil penalty were discussed.

Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20220916112619

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: LOVING HOME CARE	FACILITY NUMBER: 015601469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/22/2022 Section Cited CCR 87705(f)(1)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	R1 no longer lives in the facility. Licensee to conduct in-service training and submit proof by 09/22/2022. A $500.00 civil penalty is assessed.
	8 9 10 11 12 13 14	-Based on interview and records review, the licensee did not comply with the section above for R1 having access to the shaver resulting in R1 sustaining cuts on the fingers. Civil penalty is assessed.	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: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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
09/16/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220916112619

FACILITY NAME:	LOVING HOME CARE		FACILITY NUMBER:	015601469
ADMINISTRATOR:	GOLDASSIO, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	22270 PERALTA STREET		TELEPHONE:	(510) 582-8839
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	5	CENSUS: 2	DATE:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Matilde Miguel Machado/Licensee and Robert Goldassio/Operations Manager		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility threatened to evict resident (R1)

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Matilde Miguel Machado, licensee, and Robert Goldassio, operations manager. LPA also met with Stephanie Goldassio, administrator. LPA informed the purpose of visit.

It was alleged that when R1 is in a new setting, it can take time for R1 to go back to baseline. The facility informed R1's family member that there's in R1's behavior and that the faclilty can not provide R1's level of care needs and threatened to evict R1 if R1 is not moved out, facility will call "code".

LPA reviewed resident's record including but not limited to LIC602A Physician's Report and Admission Agreement, record of communication with R1's respponsible person. LPA interviewed staff and resident (R2).

.......continue next page (9099C)

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: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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-20220916112619

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: LOVING HOME CARE	FACILITY NUMBER: 015601469
	VISIT DATE: 09/21/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA interviewed Robert Goldassio who indicated that he was in constant communication with R1's family member regarding R1's behaviors and R1's level of care needs which facility can longer provide. Although there were talks regarding R1's move-out, Robert denied threatening to call "code" if R1 is not move out. Review of Robert's communication with R1's family member revealed Robert communicated and told the family member that a 3-day eviction process has not started yet.

LPA interviewed resident (R2) who stated that R2 has not heard the staff talking to R1's family member and threatening to evict R1.

Based on information gathered, the 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.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5