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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200544
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:24:07 AM

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
12/23/2020 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20201223122619
FACILITY NAME:AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
019200544
ADMINISTRATOR:ALBERT LEANOFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 314-0807
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:0CENSUS: 0DATE:
11/18/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff confined resident to room with door tied shut from the outside.
Facility Failed to Provide Resident with Adequate Care and Supervision
INVESTIGATION FINDINGS:
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On 11/18/2022 starting at 09:15 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation.

During the course of investigation, LPA obtained information, collected documents and interviewed staff, residents, and witnesses. Based on interviews, it was revealed facility staff had learned that R1 tested positive for COVID-19 and removed R1 from their wheelchair and left them alone in their room and witnesses observed a bungee cord tired around the door.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

A copy of the report will be mailed to the facility
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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 3
Control Number 15-AS-20201223122619
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: AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 019200544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
HSC
1569.269(a)(6)
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ยง1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered
-This requirement is not met as evidenced by:
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The Liciensee will review the regulations.
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Based on interviews, the licensee did not comply with the section above by leaving a resident on the floor in their room and not assisting them.
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Type B
11/18/2022
Section Cited
CCR
87568.1(a)(6)
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 Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building....
This requirement is not met as evidenced by:
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The Liciensee will review the regulations.
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Based on observation and interviews, Licensee did not comply with the regulation cited above by locking a resident into a room and securing the door shut from the outside which poses an immediate personal rights 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20201223122619
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: AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 019200544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights
(a) ... each client shall have personal rights which include, but are not limited to, the following: (3) To be free from...punishment, infliction of pain, humiliation, intimidation... threat, mental abuse... physical functioning.
This requirement was not met as evidence by:
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The Liciensee will review the regulations.
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Based on LPA's interviews the Licensee did not comply with the section cited above by frocfully removing a resident from their wheelchair onto the floor.
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CCR
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3