019200464-3-11-2022-15-AS-KHOS-CCRKF2-20220322075114

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200464
Report Date: 03/11/2022
Date Signed: 03/11/2022 09:27:24 AM

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
08/26/2020 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200826083903

FACILITY NAME:	J & C CARE CENTER LLC		FACILITY NUMBER:	019200464
ADMINISTRATOR:	CHING, JESSICA		FACILITY TYPE:	740
ADDRESS:	4240 REDDING STREET		TELEPHONE:	(510) 482-0108
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94619
CAPACITY:	25	CENSUS: 24	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jessica Ching, Administrator		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed pressure injuries while in care
Staff failed to address scabies outbreak
Staff threatened resident with eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/11/22 at 8:30am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and deliver investigation findings. LPA explained the purpose of the visit with administrator.

Allegation: Resident developed pressure injuries while in care – Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that redness was observed on 8/10/20, and that when a wound developed the following day the facility immediately transferred the resident to the hospital. Licensing and R1’s family were informed at the time. After few days of hospital stay, hospital determined R1 would be admitted to Suncrest Hospice services. Suncrest hospice provided Care Plan for R1. Administrator was in constant communication with family members, hospital, and hospice, and also informed licensing regarding R1’s changing of condition and recovering progress.

Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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 2

Control Number 15-AS-20200826083903

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: J & C CARE CENTER LLC	FACILITY NUMBER: 019200464
	VISIT DATE: 03/11/2022

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

Allegation: Staff failed to address scabies outbreak – Unsubstantiated

The Department has investigated this allegation and per records review and interviews, R1 was transferred to hospital on 7/9/20 and discharged on 7/10/20. Hospital documentation did not indicate that R1 had scabies and there was no evidence obtained to indicate that R1 had scabies after returning to the facility.

Allegation: Staff threatened resident with eviction – Unsubstantiated

The Department has investigated this allegation and per records review and interviews, R1’s son (W3) stated that his mother (W5, spouse of R1) was chronically late with payments to the facility; and found no evidence that an eviction letter had been drafted and presented to the resident or family.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2