019200389-10-10-2022-15-AS-YFLS-CM3RHR-20221213120245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200389
Report Date: 10/10/2022
Date Signed: 10/10/2022 02:15:46 PM

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
10/04/2022 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20221004130028

FACILITY NAME:	BROADMOOR HOUSE #2		FACILITY NUMBER:	019200389
ADMINISTRATOR:	DOMINIQUE M. MELLION		FACILITY TYPE:	735
ADDRESS:	83 EUCLID AVENUE		TELEPHONE:	(510) 677-5855
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	6	CENSUS: 6	DATE:	10/10/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Dominique Mellion, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility did not accept resident back after hospitalization.

INVESTIGATION FINDINGS:

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On 10/10//2022 at 11:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit for the above allegation. LPA met with S3 and explained the purpose for the visit. S3 telephoned S1 who advised LPA that S2 would arrive in about 10 minutes. At 11:55 AM LPA met with S2.

During the course of the visit, LPA requested and reviewed the following documents: Pre-Placement Appraisal, Admission Agreement, Individual Program Plan, Physician's Report(s), R1’s Medical Progress Notes and RCEB Vendor Special Incident Report(s).

continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

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-20221004130028

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: BROADMOOR HOUSE #2	FACILITY NUMBER: 019200389
	VISIT DATE: 10/10/2022

NARRATIVE

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...continued from LIC9099

LPA interviewed two (2) Care Staff and two (2) Witnesses. After interviews were conducted and records were reviewed there was no documentation in the records or interviews that revealed the allegation, “Facility did not accept resident back after hospitalization”. On 09/06/22 S1 notified CCL of the change in C1's medical condition. A 30-day notice was submitted to CCL, RCEB and C1 on 09/06/22. The notice expired and no action was taken against C1. C1 was admitted to the hospital on 09/28/22 and needed treatment for unexplained weakness in his/her legs. Per the Nurse’s notes from the hospital on 09/30/22, C1 required total assistance of his/her ADL’s. Due to a change in C1’s medical condition, and needs and services, S1 was unable to accept C1 back to the facility and unable to provide the proper level of care for C1. RCEB’s assessment on 10/05/22 revealed that C1 will need alternative placement for intermediate care and rehabilitation. LPA interviewed W1 and RCEB currently has procedures in place to locate C1 to a facility for intermediate and post care. Per S1, the Puchase of Service from RCEB has been canceled.

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 to Administrator, Dominique Mellion.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC9099 (FAS) - (06/04)

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