019200139-9-11-2024-15-AS-KHOS-D97HSG-20240917062707

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200139
Report Date: 09/11/2024
Date Signed: 09/11/2024 06:15:38 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
08/17/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220817123402

FACILITY NAME:	NEW BELLEVUE MANOR		FACILITY NUMBER:	019200139
ADMINISTRATOR:	SHIELHA MUNIZ		FACILITY TYPE:	735
ADDRESS:	3056 RANDALL WAY		TELEPHONE:	(510) 538-3053
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	12	CENSUS: 8	DATE:	09/11/2024
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Juliana Taburaza/Licensee and Sheilha Muniz/Administrator		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff hit resident in care.

-Resident hit another resident while in care.

-Staff do not ensure resident is taking prescribed medication.

-Staff does not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Juliana Taburaza, licensee, and Sheilha Muniz, administrator, and informed the purpose of visit.

During the course of investigation, LPA reviewed residents' file and obtained copies of the following residents' documents: LIC602 Physician's Report; LIC601 Identification and Emergency Contact Information; Individual Program Plan; Appraisal/Needs and Services Plan; Medication Administration Record (MAR). LPA reviewed the Special Incident Reports (SIRs) that were submitted by the facility to the Department. LPA interviewed staff (S1, S2, S3), licensee, administrator and 2 residents on 08/22/2022 and 12/09/2022.

......continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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 2

Control Number 15-AS-20220817123402

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: NEW BELLEVUE MANOR	FACILITY NUMBER: 019200139
	VISIT DATE: 09/11/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff hit resident (R1).
All staff interviewed denied the allegation and indicated it is R1 who hit other residents which confirmed by one of the residents. Due to the other resident’s medical condition and diagnosis, LPA was not able to obtain information from this resident. Review of R1’s records showed R1 has aggressive behaviors. SIRs showed R1 hit other residents.

Allegation: Resident hit another resident (R1) while in care,
R1 stated that other resident fights her. One of the residents interviewed stated it is R1 who hit other residents. The 2 staff stated it is R1 who hit other resident and when it happens, they redirect the residents. One of these staff indicated when R1’s family member comes to the facility, other residents complain to the family member about R1’s behaviors.

Allegation Staff do not ensure resident is taking prescribed medication.
R1 stated she does not want to take one of her medications because of the taste and that her sister told her not to take that medication. Staff interviewed confirmed R1’s statement. S1 stated R1 hid the medication under her tongue and spit in the sink while S2 stated R1 put the medication in the tissue paper. During another interview on 12/09/22, S1 stated that R1 listened to her family member and was already taking all her medications.

Allegation: Staff does not treat resident with dignity and respect.
All 3 staff interviewed denied the allegation.

Based on all information obtained, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2