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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200281
Report Date: 09/04/2020
Date Signed: 09/04/2020 02:21:44 PM



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
02/14/2020 and conducted by Evaluator Yvonne Flores-Larios
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200214163839
FACILITY NAME:DICHONDRA PLACEFACILITY NUMBER:
019200281
ADMINISTRATOR:CARLA HERNSTROMFACILITY TYPE:
735
ADDRESS:5772 DICHONDRA PLACETELEPHONE:
(510) 894-1413
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:3CENSUS: 3DATE:
09/04/2020
ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caroline Koorn, Administrator TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff are not following client's ISP plan

Staff falsifying client's records

Staff is altering client's medication without proper consent
INVESTIGATION FINDINGS:
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On September 4, 2020 Licensing Program Analysts (LPAs) Y. Flores-Larios, J. Jackson, and J. Williams conducted an announced tele-visit with facility administrator Caroline Koorn and Carla Hernstrom, Quality Assurance for Alegria and Humphrey Kasweka, lead staff. The purpose of the visit is to deliver complaint findings for the allegations above. Due to current shelter in place issued by the Governor visit is being conducted via tele-visit.

On 2/14/2020 the regional office recieved the complaint with listed allegations above. LPA K. Chow-Yau conducted initial 10-day visit on 2/21/2020 and collected relevant documentation. On 8/31/2020 LPA Y. Flores-Larios received additional documentation to include R1's Centrally Stored Medication Logs (MAR), weight logs, and clinicial notes for day to day progress identified in R1's Individualized Service Plan (ISP) from January 2020 to present. On the allegation that staff are not following clients ISP plan. LPA reviewed daily clinical notes and each targeted goal written in the ISP, however there is not sufficient information to prove or disprove the allegation.
(Continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020
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-20200214163839
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: DICHONDRA PLACE
FACILITY NUMBER: 019200281
VISIT DATE: 09/04/2020
NARRATIVE
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 On the allegation that staff are falsifying clients records and staff is altering clients medication without proper consent it was noted on R1's MARs that medications were given as prescribed however medical documentation dated 2/18/2020 stated from psychiatrist that R1 blood work did not have levels of particular medication noted in bloodstream.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4