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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200131
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:02:45 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
08/31/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210831150456
FACILITY NAME:IRAAS RESIDENTIAL CAREFACILITY NUMBER:
019200131
ADMINISTRATOR:MOMO R. DUOAFACILITY TYPE:
735
ADDRESS:1503 VIRGINIA STREETTELEPHONE:
(510) 289-5066
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 6DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Deborah Lockhart, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Resident was injured by another resident while in care.
Resident(s) are not being adequately supervised while in care.
INVESTIGATION FINDINGS:
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On 1/25/2023 at 1:10PM, Licensing Program Analysts (LPAs) G. Luk and G. Clark arrived unannounced to deliver findings in regards to the allegations above. LPAs met with Administrator, Deborah Lockhart.

During the course of investigation, LPA G. Luk interviewed 5 clients, 3 staff, and complainant. LPAs obtained and reviewed documents including physician's report, IPP (Individual Program Plan), admission agreement, emergency information, and care notes.

Resident was injured by another resident while in care.
Interview with clients and staff revealed that C1 has scratched and hit other clients at the facility.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 4
Control Number 15-AS-20210831150456
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: IRAAS RESIDENTIAL CARE
FACILITY NUMBER: 019200131
VISIT DATE: 01/25/2023
NARRATIVE
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Resident(s) are not being adequately supervised while in care.
C1's IPP dated 3/12/2021 indicates that C1's case manager is seeking 2:1 care for C1. Interview with staff revealed that C1 is currently receiving 1:1 care. On 9/9/2021, LPA G. Luk was hit by C1 while waiting in the hallway to interview another client. There was no 1:1 staff with C1 at the time of incident. One staff was in the living room and another staff was in the kitchen. There was a total of 3 staff working at that time.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210831150456
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: IRAAS RESIDENTIAL CARE
FACILITY NUMBER: 019200131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited
CCR
80072(a)(2)
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Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
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Facility has agreed to provide a written plan to mitigate clients from getting injured by another client and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by clients being injuried by another client which poses an immediate health and safety risk to the persons in care.
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Type A
01/26/2023
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care and Supervision. The licensee shall provide those services...as necessary to meet the client's needs. This requirement is not met as evidence by:
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Facility has agreed to provide a written plan to have 1:1 care for C1 as stated in IPP and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having a 1:1 staff with C1 which poses an immediate health and safety risk to the persons in care.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/31/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210831150456

FACILITY NAME:IRAAS RESIDENTIAL CAREFACILITY NUMBER:
019200131
ADMINISTRATOR:MOMO R. DUOAFACILITY TYPE:
735
ADDRESS:1503 VIRGINIA STREETTELEPHONE:
(510) 289-5066
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 6DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Deborah Lockhart, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Resident sustained multiple injuries (marks, bruises, scratches) while in care.
INVESTIGATION FINDINGS:
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On 1/25/2023 at 1:10PM, Licensing Program Analysts (LPAs) G. Luk and G. Clark arrived unannounced to deliver findings in regards to the allegation above. LPAs met with Administrator, Deborah Lockhart.

During the course of investigation, LPA G. Luk interviewed 5 clients, 3 staff, and complainant. LPAs obtained and reviewed documents including physician's report, IPP (Individual Program Plan), admission agreement, emergency information, and care notes.

Interview with staff revealed that C5's bruises were due to falls from having seizures on 8/19/2021 or 8/20/2021. Interview with clients indicated the scratches were caused by a client. Staff would intervene when client has behaviors towards another client. There's no evidence that staff caused injuries to C5.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 4