019200131-2-7-2023-15-AS-BFOG-CP23AH-20230213170442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200131
Report Date: 02/06/2023
Date Signed: 02/07/2023 02:46:16 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
01/13/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20230113151308

FACILITY NAME:	IRAAS RESIDENTIAL CARE		FACILITY NUMBER:	019200131
ADMINISTRATOR:	MOMO R. DUOA		FACILITY TYPE:	735
ADDRESS:	1503 VIRGINIA STREET		TELEPHONE:	(510) 969-5107
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	6	CENSUS: 6	DATE:	02/06/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ifeoma Ekwezla, Caregiver		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff locked residents inside of their rooms.

INVESTIGATION FINDINGS:

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This is an admendment to an original report dated 2/6/2023

On 2/7/2023 at 10:00 AM, Licensing Program Analysts (LPAs) C. Fowler and L. Alexander arrived unannounced to deliver findings for the above allegation. LPAs met with Emeka Alicha, Supervisor and explained the purpose of the visit.

During the course of the investigation LPA conducted a tour of the facility and interviewed 5 staff, 5 clients, 1 witness and Reporting Party (RP); and obtained & reviewed the followings documents: facility and staff roster, IPP/ISP, physician's report, emergency information, incident reports and caregiver work schedule.

Continue on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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-20230113151308

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: 02/06/2023

NARRATIVE

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Continue from LIC9099

W1 stated that on 1/12/2023 that W1 reported to the facility and observed that C4 was knocking on the door of his bedroom and exclaiming, that he was wet for approximately 10 minutes. W1 stated at this time the door for C4 room was locked from the outside and no care staff were attending to C4. W1 further stated that W1 had to unlock the door from the outside. C4 then went to the living room to seek a care staff. W1 stated C2 was also in the bedroom playing video games. W1 stated C4 was in the common area and approached C1 and C1 grabbed C4 twice, care staff then put C4 back into the bedroom and locked the door. W1 stated that there have been other occasions when C4 bedroom door has been locked since this allegation.

C2 stated that while care staff are cooking and cleaning, they don’t want to be bothered by C4 so care staff lock C4 in the bedroom. During visit LPA observed that the lock was on the inside of the room, however C2 stated the lock for C4 bedroom door was facing the outside but had been switched to the inside.

Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230113151308

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: 02/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely Type B 02/13/2023 Section Cited CCR 80072(a)(7)	1 2 3 4 5 6 7	(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night.	1 2 3 4 5 6 7	Administrator agreed to remove the lock from all bedroom doors and submit photos to CCLD no later then the POC date.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee did not comply with the section cited above by locking clients in their bedrooms, which poses a potential health and safety risk to persons in care.	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) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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