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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200655
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:29:36 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
10/30/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241030164909
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: 6DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Gina White, Caregiver.TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff not providing adequate supervision.
INVESTIGATION FINDINGS:
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On 12/03/2024 around 11:45 AM, LPA L. Holmes amended the report to update the allegations and met with Gina White, Caregiver.
On 11/07/2024 around 11:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a 10-day complaint investigation for the above allegations. LPA met with Care Staff Gina White, and Nicholas Marcelo. LPA delivered the findings of the complaint to Katelyn Salvador Administrator (ADM) and explained the purpose for the visit.

During the course of the investigation and visit, LPA conducted interviews with Staff (S1, S3, S4) and Witness #1 (W1). LPA requested current Personnel Report (LIC 500), UIR for Client #1 (C1), C1's Medication Administration Records (MAR) for 10/2024 & 11/2024, RCEB consumer agreement, Appraisal/Needs and Services Plan, Community Health Progress Notes, IPP, and Physician's Report dated 07/30/24.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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-20241030164909
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: 12/03/2024
NARRATIVE
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...continued from LIC9099.

Allegation: SUBSTANTIATED

For the allegation staff not providing adequate supervision,

Interviews with S1, S3, S4 and W1 revealed that a Serious Incident Report (SIR) on 10/11/24 was submitted to RCEB, CCLD, and the family that confirmed S4 was supervising C1 and was aware that C1 had left the facility. S2 was present at the facility also but stayed behind to assist C2. S4 attempted to follow C1 in the neighborhood. As C1 approached the local bridge, S4 asked C1 to go back home. C1 become aggressive and charged towards S4. S4 took a few steps away from C1 and C1 began to run towards S4. S4 stated that he/she and C1 were both running and approaching a nearby school as C4 kept looking back but when S4 looked back again C1 had gone in a different direction. While at the local school, S4 looked around for C1 but did not know where C1 went. S4 called the Union City Police Department (PD) while at the school, searched the area again while waiting for the PD to arrive. Once the PD arrived, they began searching the area with S4. S4 returned to the facility. S4 and S1 called the PD and was advised that C1 had been located and transported to Washington Hospital in Union City, CA for evaluation, therefore the allegation is substantiated.


The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiency cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, a copy of this report and appeal rights provided to Gina White, Caregiver.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20241030164909
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: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2024
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.-This requirement is not met as evidenced by:
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ADM to complete an updated appraisal needs and service plan to address the behaviors of C1, and a plan for Staff to attend to C1 at all times while leaving the facility. Provide in-service training and updated plan to CCLD by POC date.
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Based on interviews, the licensee did not comply with the section cited above not attending to C1 at all times when leaving the facility which poses/posed a potential health, safety and/or 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3