019200331-4-14-2023-15-AS-KHOS-CT6JCP-20230626065615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200331
Report Date: 04/14/2023
Date Signed: 04/14/2023 11:55:18 AM

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
02/23/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230223154343

FACILITY NAME:	COVENTRY CARE HOME		FACILITY NUMBER:	019200331
ADMINISTRATOR:	MARIDEL Q. CORTEZ		FACILITY TYPE:	735
ADDRESS:	4284 COVENTRY WAY		TELEPHONE:	(510) 972-0861
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 3	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	MARIDEL Q. CORTEZ, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff did not assist client with meeting medical needs
Staff did not ensure client's hygiene needs were met
Staff did not ensure client's clothing was laundered
Staff did not ensure that client's belongings were safeguarded

INVESTIGATION FINDINGS:

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On 4/14/2023 at 9:50AM Licensing Program Analyst (LPA) K. Nguyen, arrived unannounced to conduct investigation on the above allegations. LPA met with Administrator, Maridel Cortez, and explained the purpose of the visit.

It was alleged that Staff did not assist client with meeting medical needs. However, during the course of investigation, LPA reviewed C1 IPP, medication log, blood pressured log, doctor visit summary, and interviewed staffs. S2, and S3 states “C1 only have one medication, and we log it on our Routine Medication Record”. S2 and S3 states that we brought C1 to one doctor appointment and got everything done, beside the stool sample. S2 and S3 explained that C1 was only going to stay for 31 days. S2 explained and asked C1 doctor if it okay if C1 family member can turn in the stool sample in two weeks, because C1 will be leaving the facility. Doctor stated to S2 that it’s not urgent and can be turn in anytime. Therefore, the allegation is unsubstantiated.

Reports continue on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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-20230223154343

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: COVENTRY CARE HOME	FACILITY NUMBER: 019200331
	VISIT DATE: 04/14/2023

NARRATIVE

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It was alleged that Staff did not ensure client's hygiene needs were met. However, during the course of investigation, LPA interviewed S1, S2, and S3 states that “we make sure that C1 washed clothes once a week, and we reminded C1 to shower daily”. S1, S2, and S3 states C1 have a routine of taking a shower after lunch time. During the time that C1 family pick C1 up it was too early for C1 to take a shower, and C1 was in a rush therefore C1 put on the dirty clothes that C1 wore the day before. S1, S2, and S3 sates C1 never smell or wore any dirty clothes. Therefore, the allegation is unsubstantiated.

It was alleged that Staff did not ensure client's clothing was laundered. However, during the course of investigation, LPA interviewed S1, S2, and S3 states C1 does C1 own laundry. S1, S2, and S3 reminded C1 to do laundry once a week, which is C1 weekly routine. S1 states C1 never wear dirty clothes. Therefore, the allegation is unsubstantiated.

It was alleged that Staff did not ensure that client's belongings were safeguarded. However, during the course of investigation, LPA spoke with RP to confirmed which belonging where missing. RP stated that C1 belonging is all there nothing is missing. Therefore, the allegation is unsubstantiated.

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.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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