019200131-2-7-2023-15-AS-BFOG-CP23AG-20230213170442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200131
Report Date: 02/06/2023
Date Signed: 02/07/2023 12:20:41 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 2/6/2023 at 2:00 AM, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to deliver findings for the above allegation. LPAs met with Administrator, Deborah Lockhart 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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