<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200313
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:32:30 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
04/24/2023 and conducted by Evaluator Carol Fowler
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230424135555
FACILITY NAME:ARCYAN CARE HOMEFACILITY NUMBER:
019200313
ADMINISTRATOR:MARCY DELA CRUZFACILITY TYPE:
735
ADDRESS:172 TAMARACK DRIVETELEPHONE:
(510) 928-2650
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 4DATE:
05/04/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amenda Grafia, CaregiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client locked in bedroom.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/04/2023 at 10:00 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings for the above allegation. LPA met with Amenda Grafia, Caregiver and explained the purpose of the visit.
Administrator Marcy Dela Cruz arrived at approximately 11:00AM

During the course of the investigation LPA conducted a tour of the facility and interviewed 3 staff, and 2 clients. LPA reviewed the following documents: facility and staff roster, IPP/ISP, physician's report, emergency information, incident reports, appraisal needs and service plan, physician report and notes from meeting with RCEB conducted on 5/03/2023.

Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
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 3
Control Number 15-AS-20230424135555
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: ARCYAN CARE HOME
FACILITY NUMBER: 019200313
VISIT DATE: 05/04/2023
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
Continue from LIC 9099

RP stated that on 04/04/2023 while visiting the facility C1 bedroom door was locked. RP questioned staff (S2 and S3) as to why the door was locked, staff informed RP that the door was locked because C1 will get up and gorge on food in the refrigerator and could possibility choke and/or AWOL. During tour RP asked C1 to unlock the bedroom door and after several attempts C1 was unable to unlock the door.

While conducting interviews with S1, S2 and S3 all stated that they don't know who locked the door and it could have possibly been C1 because she plays with the doorknob when she is board and C1 knows how to lock and unlock the door, but if you're a new face she will not cooperate and will push you away.

Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230424135555
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: ARCYAN CARE HOME
FACILITY NUMBER: 019200313
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2023
Section Cited
CCR
80072(a)(7)
1
2
3
4
5
6
7
(a) Except for... facilities, each ...are not limited to,... (7) Not to be locked in any room,... premises by day or not. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to remove the lock from C1 bedroom door and conduct in-service with staff and will submit signatures and photos to CCLD no later than the POC date.
8
9
10
11
12
13
14
Based on interviews and record reviews, the licensee did not comply with the section cited above by locking a client in their bedroom, which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Administrator has been in a meeting with RCEB which consulted with ID Team and it was approved to replace C1 door know with an un-lockable one.
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: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3