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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200655
Report Date: 01/12/2024
Date Signed: 01/12/2024 01:48:56 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
01/08/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240108112058
FACILITY NAME:ALOHA RESIDENTIAL CARE INCFACILITY NUMBER:
019200655
ADMINISTRATOR:KATELYN SALVADORFACILITY TYPE:
735
ADDRESS:34706 WILLIAMS WAYTELEPHONE:
(510) 972-0900
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Gina WhiteTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff not supervising resident resulting in multiple injuries.
INVESTIGATION FINDINGS:
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On this day at around 10:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct investigation on the above allegation and met with Co Administrator Gina White. LPA explained to White the purpose of the visit.

During the visit, LPA obtained and reviewed Client 1 (C1) IPP, Physician's Report, Register of Clients and Lic 500. Based on C1's IPP dated 6/17/2019, C1does not have much safety awareness. C1 does not pay attention to the surroundings. C1 needs supervision at home and in the community for safety.
LPA was provided by Reporting Party (RP) of C1's previous photos with bruises on both arms and knees and wounds on the arms.

Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D. continuation on Lic 9099C


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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
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
01/08/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240108112058

FACILITY NAME:ALOHA RESIDENTIAL CARE INCFACILITY NUMBER:
019200655
ADMINISTRATOR:KATELYN SALVADORFACILITY TYPE:
735
ADDRESS:34706 WILLIAMS WAYTELEPHONE:
(510) 972-0900
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Gina WhiteTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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9
Staff not providing client with sufficient amount of water to drink.
Staff not assisting client with hygiene
INVESTIGATION FINDINGS:
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On this day, LPA Luisa Fontanilla arrived unannounced to conduct investigation on the above allegation and met with CoAdministrator Gina White. LPA explained to White the purpose of the visit.

During the visit, LPA intervewed White and reviewed Client 1 (C1) Individual Program Plan (IPP) and Physician's Report. C1's PR indicates C1 is ambulatory and is able to care for own toilet needs, dress and feed self. In regards to bathing, C1 would need assistance from staff.

During interview conducted with Staff 1 (S1), S1 states staff assist C1 with showers and dressing. C1's IPP indicates C1 has obsessive behaviors and has the tendency to wear the same clothes even though they are old/torn off. S1 confirmed with LPA the behavior of C1 insisting on wearing the same purple dress and underwear everytime C1 goes out. S1 states that staff would handwash C1's underwear and get it dried each time so C1 can go out with family member.
continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20240108112058
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: ALOHA RESIDENTIAL CARE INC
FACILITY NUMBER: 019200655
VISIT DATE: 01/12/2024
NARRATIVE
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In regards to C1's water intake, S1 states C1 has own water bottle (1000ml) in the room that gets filled at least 3x a day. S1 states C1 drinks a lot of water, milk and juice. During the visit, LPA observed C1's skin did not appear dry/dehydrated.

LPA was unable to interview C1 as C1 is nonverbal.

Based on observation and interview conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240108112058
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: ALOHA RESIDENTIAL CARE INC
FACILITY NUMBER: 019200655
VISIT DATE: 01/12/2024
NARRATIVE
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Exit interviews was conducted with White and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240108112058
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: ALOHA RESIDENTIAL CARE INC
FACILITY NUMBER: 019200655
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
Based on record review and interview conducted, facility did not comply with
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Administrator will conduct in-service training on C1's IPP regarding safety awareness on how to prevent C1 from sustaining injuries and submit proof of training to CCL.
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section above when C1 sustained wounds and bruises on the arms and knees while living at the facility. C1's IPP indicates C1 lacks safety awareness and needs staff supervision
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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: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5