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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200395
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:35:48 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
07/15/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240715152629
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:
07/16/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rashpal Waraich, Licensee TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not meeting the needs of the resident
INVESTIGATION FINDINGS:
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On 07/16/2024 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and deliver the finding for the above allegation. LPA met with Jean Rodriguez, Administrator (ADM) and explained the reason for visit. Licensee Rashpal Waraich, arrived after about twenty (20) minutes later.

Allegation:
Staff are not meeting the needs of the resident

During the course of the investigation and visit, LPA toured the facility, reviewed Client #1 (C1s) files, conducted Staff (S1 & S2) interviews, requested the ID/Emergency contact information for C1 along with communications sent to responsible parties regarding C1's stay at the facility, and the following documents were requested: Current Personnel Report (LIC 500), LIC 500 for 06/2024, Resident Roster, C1's Individual Service Plan, current IPP and Physician's Report (LIC 602).
Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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 3
Control Number 15-AS-20240715152629
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: 07/16/2024
NARRATIVE
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...continued from LIC 9099.

Although S1 and S2 denied the allegation, interviews with S1, S2 and Witness #1 (W1) revealed that the facility did not make provisions to provide one on one (1:1) care for C1 at all times. Records from C1’s physician and family dated 12/28/2023 states that C1 needs to be watched at all times. S2 stated that there were three (3) Care Staff employed and one (1) of those three (3) was in training. S2 stated that she/he has it’s own Administrator duties also for the care of the six (6) clients. Interviews further revealed that the facility did not have an adequate number of staff to ensure the proper supervision for C1. The Regional Center of the East Bay (RCEB) was provided a request for additional support that was dated 04/28/24, but the facility did not make provisions for additional care while awaiting approval.

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



Deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within a 12 month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided to Rashpal Waraich, Licensee.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240715152629
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: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2024
Section Cited
CCR
85065(b)
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85065 Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
-This requirement is not met as evidenced by:
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Administrator/Licensee to read the regulations, provide training to staff, submit proof of attendee’s signatures, and devise a plan to ensure the proper care and supervision of clients in care.
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-Based on interviews and observation, the licensee did not comply with the section above by not employing staff as necessary to ensure provision of care and supervision to meet Client’s (C1’s) needs.
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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: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3