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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200395
Report Date: 07/02/2024
Date Signed: 07/02/2024 08:29:27 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
06/27/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240627081442
FACILITY NAME:PECO CARE HOMEFACILITY NUMBER:
019200395
ADMINISTRATOR:JEAN B. RODRIGUEZFACILITY TYPE:
735
ADDRESS:34914 PECO STREETTELEPHONE:
(510) 589-9419
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jean Rodriguez/Administrator
and Rashpal Wairaich/Licensee 		TIME COMPLETED:
07:45 PM
ALLEGATION(S):
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-Staff not treating residents with dignity.

-Staff serve expired food to residents.
INVESTIGATION FINDINGS:
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At 2:15 p,m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Jean Rodriguez, administrator, and informed the reason for visit. Rashpal Waraich, licensee, arrived after several minutes.

During the course of investigation, LPA conducted inspection, reviewed residents' records, and obtained copies of documents. LPA interviwewed staff (S1, S2, S3, S4, S5 and S6), and 3 residents.

Allegation: staff not treating residents with dignity.
Reporting party (RP) stated that residents experienced put-downs, harassed and threatened by S1 that if they can not follow the rules, they can leave. It was further alleged that S1 yells at the residents.

......continued on 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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 5
Control Number 15-AS-20240627081442
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: PECO CARE HOME
FACILITY NUMBER: 019200395
VISIT DATE: 07/02/2024
NARRATIVE
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Although S1 denied the allegations, the other 5 staff interviewed stated S1 at times raised voice to the residents. One of these 5 staff stated that there's a time when S1 spoke sternly to the residents. The 3 residents stated S1 raised voice on residents.

Allegation: staff serve expired food to residents.
RP stated staff were instructed by S1 to serve expired food to the residents. RP further stated that there are food items with mold. Although S1 denied the allegation, two of the staff stated they were instructed by the statf to serve the expired food. Another staff stated there are food items that are expired, however. this staff stated she tastes it first before serving to the residents and does not serve it's no longer good. LPA conducted inspection, randomly checked the food supplies, and observed expired cheese, pesto and sour cream. LPA also observed strawberries and onions with mold.

Based on information obtained, the allegations are substantiated, A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the licensee and administrator.

Exit interview conducted. Appeal Rights. LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240627081442
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: PECO CARE HOME
FACILITY NUMBER: 019200395
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
80076(a)(1)
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80076 Food Services: (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.....All food shall be selected, stored, prepared and served in a safe....
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Staff threw away the expired items.

In additiion. adminstrator to do the following, and submit proof by 7/03/24:
1 Check all the food supplies.
2. In-service the staff.
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-This requirement is not met as evidenced by:
-Based interview and observation, the licensee did not comply with the section above in having expired food supplies which pose an immediate health and/or personal right risks to persons in care.
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Type B
07/16/2024
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights: (a) .....each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
-This requirement is not met as evidenced by:
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Administrator to read the Regulations and have the staff in-serviced. Copy of in-service training with attendees signatures to be submitted by 7/16/24.
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-Based on interviews, the licensee did not comply with the section above when staff treated the residents inappropriately which poaed a piotential 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: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/27/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240627081442

FACILITY NAME:PECO CARE HOMEFACILITY NUMBER:
019200395
ADMINISTRATOR:JEAN B. RODRIGUEZFACILITY TYPE:
735
ADDRESS:34914 PECO STREETTELEPHONE:
(510) 589-9419
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jean Rodriguez/Administrator
and Rashpal Wairaich/Licensee 		TIME COMPLETED:
07:45 PM
ALLEGATION(S):
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Staff improperly administered medications to resident.
INVESTIGATION FINDINGS:
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At 2:15 p,m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Jean Rodriguez, administrator, and informed the reason for visit. Rashpal Wairaich, licensee, arrived after several minutes.

During the course of investigation, LPA conducted inspection, reviewed resident's (R1) doctor's order of medications, residents (R1 and R2) Medication Administration Records and LIC622 Centrally Stored Medication and Destruction Records. LPA interviewed staff (S1, S2, S3, S4, S5 and S6).

It was alleged that S1 gave intruction to staff to administer resident (R1) Seroquel to resident (R2). Two of the staff (S2 and S3) stated S1 gave instruction fo them to administer R1's Seroquel to R2. S1 denied the allegation. The other 3 staff stated they don't administer medications. Review of records showed the medication is administered to the right residents. Due to medical condition/diagnosis, LPA was not able to obtain information from the resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240627081442
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: PECO CARE HOME
FACILITY NUMBER: 019200395
VISIT DATE: 07/02/2024
NARRATIVE
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Based on the information gathered and LPA not able to obtain information from the resident, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5