019200286-12-22-2023-15-AS-YFLS-D22MCS-20240201083001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200286
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:24:46 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
06/14/2023 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230614112727

FACILITY NAME:	GREEN OAK DEVELOPMENTAL CENTER II		FACILITY NUMBER:	019200286
ADMINISTRATOR:	MARIA LEANO		FACILITY TYPE:	775
ADDRESS:	2827 WHIPPLE ROAD		TELEPHONE:	(510) 475-6069
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	60	CENSUS: 18	DATE:	12/22/2023
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Maria Leano		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Lack of supervision resulting in client sustaining unexplained burns while in care

INVESTIGATION FINDINGS:

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On this day at around 1:10 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding for the above allegation. LPA met with Maria Leano, Program Administrator and Gina Rivera, Licensee and explained the purpose of the visit.

On 6/14/2023, the Oakland Adult and Senior Care Program Regional Office received a complaint regarding an allegation “lack of supervision resulting in client sustaining unexplained burns while in care.” The complaint was referred to the Investigations Branch (IB) and was accepted as full investigation.
On 6/15/2023, LPA Luisa Fontanilla conducted a 10-day investigation and obtained records.

During the course of investigation, the Department conducted interviews and record reviews.

continuation on Lic 9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

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-20230614112727

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: GREEN OAK DEVELOPMENTAL CENTER II	FACILITY NUMBER: 019200286
	VISIT DATE: 12/22/2023

NARRATIVE

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On 6/9/2023, Client 1 (C1) location was only between the home and day program.
Clinical report completed by facility nurse (S12) indicates that at about 0830 hours, C1 left the facility for day program and C1 had no signs of pain or discomfort. Day Program Staff 3 (S3) documented that C1 was dropped off at day program at about 0914 or 0919 and picked up by facility Staff 9 (S9) at about 1334 hours.

S12 documented in the Nurse Progress Notes that at about 1410 hours, C1 returned home from day program with a burn on the left arm. Staff 14 (S14) changed C1’s clothes and observed C1 with a burn on the left arm. S3 called Day Program Director Maria Leano to ask what happened to C1 and why C1 has a burn on the left arm.

Interviews with day program staff revealed consistent statements of denying any knowledge into how C1 sustained a burn to the left arm on 6/9/2023. Staff statements were consistent about C1 having a normal day at day program and C1 was happy. S2, S3 and S4 were the staff mainly supervising C1 and had inconsistent statements about who was responsible for C1. S4 admitted that C1 was sitting at S4’s table and was to supervise C1 on 6/9/2023. S4 stated that S4 was gone on 6/9/2023 from 1000 hours to 1200 hours to get food for the clients. S3 admitted to only helping C1 eat lunch despite S2 stating that S3 was responsible for C1 on 6/9/2023. S2 and S4 admitted to changing C1’s diaper at 1000 hours and again at about 1249 hours or at 1300 hours. S4 and S2 had consistent statements of not noticing or witnessing C1’s top clothes being wet. After changing C1, C1 was placed back into the activities room.

On 11/30/2023, LPA interviewed S12 who states that C1 had eggs/vegetable wrap, milk and juice for breakfast before going to the day program. S12 states C1 is never given anything hot to drink.

Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is cited on the attached Lic 9099D.

No civil penalty was issued today. LPA will have to come back to issue civil penalty once determination has been made.

Exit interview was conducted and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230614112727

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: GREEN OAK DEVELOPMENTAL CENTER II	FACILITY NUMBER: 019200286
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/29/2023 Section Cited CCR 82065(a)	1 2 3 4 5 6 7	82065 Personnel Requirements (a) Program personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.	1 2 3 4 5 6 7	Administrator will train staff on: 1. communication 2. documentation Proof of training will be submitted on 12/29/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: During the course of investigation, S4 admitted that she was to supervise C1. S4 also states that S4 was gone for two hours to get foods for the clients. Staff interviewed provided conflicting information as to who was responsible for C1 while S4 was out.	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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC9099 (FAS) - (06/04)

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