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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200025
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:28:42 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
09/26/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240926141851
FACILITY NAME:ESCUETA CARE HOMEFACILITY NUMBER:
019200025
ADMINISTRATOR:ADRIAN CARLO ESCUETAFACILITY TYPE:
735
ADDRESS:1873 WEST STREETTELEPHONE:
(510) 397-0354
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 5DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Adrian Escueta/Administrator TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff mishandled a client's (C1) medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Adrian Escueta, administrator (ADM), and informed the reason for visit.

During investigation, LPA interviewed ADM who stated that the clinic informed them that R1's medications will be refilled for up to September 17, 2024; however, 1week before September 2024, the pharmacy called and informed him that C1's medications no longer have refills. C1 missed medications from September 1 to 23, 2024. LPA obtained and reviewed R1's doctor's order of medications, Medication Administration Record (MAR), Special Incident Report (SIR) and LIC622 Centrally Stored Medication and Destruction Records. MAR confirmed C1's missed 5 medications on the said dates.

......continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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 3
Control Number 15-AS-20240926141851
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: ESCUETA CARE HOME
FACILITY NUMBER: 019200025
VISIT DATE: 09/30/2024
NARRATIVE
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Based on information obtained, the preponderance of evidenced is met, therefore the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240926141851
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: ESCUETA CARE HOME
FACILITY NUMBER: 019200025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2024
Section Cited
CCR
80075(b)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

-This requirement is not met as evidenced by:
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Administrator to submit the following by 10/01/24:
1. Read the Regulations and submit self-certification.
2. Come up with a plan to ensure medications are obtained timely.
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-Based on interview and records review the licensee did not comply with the section above when C1 missed medications which posed an immediate risk to person in care.
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3. In-service the staff and submit copy of training topic with attendees signatures.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3