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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200099
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:27:47 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
01/18/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220118105814
FACILITY NAME:LADY OF MERCED CARE HOME, INC.FACILITY NUMBER:
019200099
ADMINISTRATOR:GERALDINE LARAFACILITY TYPE:
735
ADDRESS:26768 LAUDERDALE AVENUETELEPHONE:
(510) 785-8997
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 3DATE:
08/16/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria Concepcion Carlos and
Gloria Arches, Care Staff		TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident (R1) retained outside of the scope of the license.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation, and close the complaint. LPA met with care staff, Maria Concepcion Carlos and Gloria Arches, and informed the reason for visit. LPA spoke with Mercedita Lara, licensee, over the phone, Licensee can not come to the facility and authorized Maria Concepcion to sign and receive this report,

It was alleged that resident (R1) is using a walker in the facility and R1's medical assessment was not marked off if R1 is ambulatory or not. The reporting party requested for the document to be completed to indicate R1's ambulatory status but the document was never received.

During the course of investigation, LPA conducted interviews, and requested for copies of R1's documents including but not limited to LIC602 Physician's Report and Individual Program Plan. LPA reviewed the documents and facility profile and license. Facility is licensed for ambulatory only.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
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 2
Control Number 15-AS-20220118105814
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: LADY OF MERCED CARE HOME, INC.
FACILITY NUMBER: 019200099
VISIT DATE: 08/16/2022
NARRATIVE
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Licensee, staff (S1 and S2) and R1's Regional Center of East Bay (RCEB) case manager (CM) were interviewed. Licensee, S1 and S2 indicated R1 has unsteady gai. R1 may need a walker from time to time. CM indicated that the last time CM has seen R1 in person was about 2 years ago and at that time R1 was not using walker. R1's Individual Program Plan indicated R1 walks with unsteady gait and sometimes uses walker for stability when moving from one area to another; however, review of LIC602 Physician's Report showed R1 ambulatory.

Based on all information obtained and LPA unable to interview and observe R1 due to R1 has moved out of the facility, the allegation is closed as 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 report provided to Maria Concepcion Carlos.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2