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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200309
Report Date: 10/12/2021
Date Signed: 10/12/2021 04:05:55 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
08/09/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210809153414
FACILITY NAME:GLENN VIEWFACILITY NUMBER:
019200309
ADMINISTRATOR:KRISTABELLE ALATASFACILITY TYPE:
735
ADDRESS:38524 GLENVIEW DRIVETELEPHONE:
(510) 894-1971
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:3CENSUS: 4DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Josephine AbellaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not following Covid-19 protocols
Staff left a client unattended while in care
Staff do not have access to a client's personal item
Staff do not have access to a client's personal funds
INVESTIGATION FINDINGS:
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On 10/12/2021 Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to deliver investigation findings on the above allegations. LPA met with Staff Josephine Abella. Administrator Yolanda Alatas was called.

During the course of the investigation it was revealed that staff and residents go on daily walks. On multiple occasions Resident R1 leaves the staff and walks alone. R1 has returned to the faclity without any staff present at the facility on multiple occasions.

Additionally, during interviews it was revealed that on 08/09/2021 while R1 was at the facility, the only staff present did not have the key to access R1's cigarettes and cash resources.

Continued on LIC9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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 8
Control Number 15-AS-20210809153414
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: GLENN VIEW
FACILITY NUMBER: 019200309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2021
Section Cited
CCR
80026(i)(3)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (i) Immediately upon admission of a client, all of his/her cash resources entrusted to the licensee and not kept in the
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By POC date licensee agrees to create policy that ensures that the key to locked personal items and personal cash resources is always at the facility when residents are present and send a copy to CCL by fax or email.
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licensed facility shall be deposited in any type of bank, savings and loan, or credit union account meeting the following requirements: (3) The licensee shall provide access to the cash resources upon demand by the client or his/her authorized representative. This requirement was not met as evidenced by: Based on interview the licensee did not comply with the section cited above. While Resident R1 was at the facility, the only staff present did not have the key to access R1's cash resources which poses a potential health, safety, or personal rights risk to persons in care.
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Type B
10/26/2021
Section Cited
CCR
85072(b)(6)
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85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights (6) To possess and use his/her own personal items, including his/her own toilet articles. This requirement
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By POC date licensee agrees to create policy that ensures that the key to locked personal items and personal cash resources is always at the facility when residents are present and send a copy to CCL by fax or email.
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was not met as evidenced by: Based on interview the licensee did not comply with the section cited above. While Resident R1 was at the facility, the only staff present did not have the key to access R1's personal items which poses a potential health, safety, or personal rights risk to persons in care.
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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: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 15-AS-20210809153414
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: GLENN VIEW
FACILITY NUMBER: 019200309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2021
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) ... each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to
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Licensee created visitor screening log onsite. By POC date Licensee agrees to read PIN and send a copy of self-certification to CCL by fax or email.
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meet his/her needs. This requirement was not met as evidenced by: Based on interview, record review, and observation, the licensee did not comply with the section cited above. Facility does not have a visitor screening log to screen visitors for COVID-19 symptoms per PIN 21-17-ASC which poses a potential health, safety, or personal rights risks to persons in care.
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Type B
10/26/2021
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Based on
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By POC date Licensee agrees to create a plan for R1 to leave the facility with staff supervision or send updated IPP and create a plan for a staff to be present at facility when R1 returns and send a copy to CCL by fax or email.
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interview, record review, and observation Licensee did not comply with the section cited above. Resident R1 walks in the community without supervision and has returned to the faclity without any staff present at the facility which poses a health, safety or personal rights risk to persons in care.
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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: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 15-AS-20210809153414
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: GLENN VIEW
FACILITY NUMBER: 019200309
VISIT DATE: 10/12/2021
NARRATIVE
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During record view, interview, and observation it was revealed that the facility did not have a visitor screening log to screen visitors for COVID-19 symptoms per PIN 21-17-ASC.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
08/09/2021 and conducted by Evaluator Allison O'Hollaren
COMPLAINT CONTROL NUMBER: 15-AS-20210809153414

FACILITY NAME:GLENN VIEWFACILITY NUMBER:
019200309
ADMINISTRATOR:KRISTABELLE ALATASFACILITY TYPE:
735
ADDRESS:38524 GLENVIEW DRIVETELEPHONE:
(510) 894-1971
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:3CENSUS: 4DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Josephine AbellaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not have access to a client's medications
Staff do not properly maintain the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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9
10
11
12
13
On 10/12/2021 Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to deliver investigation findings on the above allegations. LPA met with Staff Josephine Abella. Administrator Yolanda Alatas was called.

During the course of the investigation it was revealed that on 08/09/2021 while Resident R1 was at the facility, the only staff present did not have the key to access R1's medications. However, R1 had already taken medications at the time and the staff who had the key returned to the facility before R1's next prescribed medication time.

While at the facility on 08/16/2021, LPA observed facility front and backyard to be well-maintained and inside facility to be clean.

Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 15-AS-20210809153414
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: GLENN VIEW
FACILITY NUMBER: 019200309
VISIT DATE: 10/12/2021
NARRATIVE
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Based on interviews conducted, observations, and records reviewed, LPA found the above allegations to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted with Staff. Copy of report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 8