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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200656
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:14:18 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
02/29/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240229112553
FACILITY NAME:JAY MAHLER RECOVERY CENTERFACILITY NUMBER:
019200656
ADMINISTRATOR:GARCIA, DENISE GFACILITY TYPE:
772
ADDRESS:15430 FOOTHILL BOULEVARDTELEPHONE:
(510) 357-3562
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:16CENSUS: 11DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Clearnise Bullard/Administrator and
Michelle Mayberry-Porter/Regional Director 		TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff leaves the medication room unlocked.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unnanounced to investigate the above allegation. LPA met with Administrator Clearnise Bullard and LVN Manager Zohal Zamir, and informed the reason for visit. LPA later met with Regional Director Michelle Mayberry-Porter.

While waiting for the administrator, LPA inspected the medication room with Zohal Zamir. LPA conducted interviews and reviewed incident reports and resident records. LPA obtained copies of documents.

Although 1 out of 5 staff stated not leaving the medication room open, 4 staff stated observing the medication room open several times. One of former residents was able to access the medication room which was confirmed by LPA with the Administrator and Regional Director.

....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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
Control Number 15-AS-20240229112553
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: JAY MAHLER RECOVERY CENTER
FACILITY NUMBER: 019200656
VISIT DATE: 03/07/2024
NARRATIVE
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Based on information obtained, the preponderance of evidence has been met, therefore the allegation is substantiated.

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

Deficiency and plan and proof of correction were discussed with the Administrator and Regional Director,

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240229112553
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: JAY MAHLER RECOVERY CENTER
FACILITY NUMBER: 019200656
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
81075(o)(2)
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81075 Health-Related Services
(o)(2) The licensee shall ensure that the client's medications are stored so that they are inaccessible to other clients in the facility.

-This requirement is not met as evidenced by:
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Administrator and/or Regional Director to conduct in-service, and submit copy of training topic with attendees signatures by 3/08/24.
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-Based on interviews, the licensee did not comply with the section for not ensuring the medication room is locked which poses an immediate risks 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: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
02/29/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20240229112553

FACILITY NAME:JAY MAHLER RECOVERY CENTERFACILITY NUMBER:
019200656
ADMINISTRATOR:GARCIA, DENISE GFACILITY TYPE:
772
ADDRESS:15430 FOOTHILL BOULEVARDTELEPHONE:
(510) 357-3562
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:16CENSUS: 11DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Clearnise Bullard/Administrator
and Michelle Mayberry-Porter/Regional Director 		TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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9
Staff (S1) spoke inappropriately to resident (R1).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unnanounced to investigate the above allegation. LPA met with Administrator Clearnise Bullard and LVN Manager Zohal Zamir, and informed the reason for visit. LPA later met with Regional Director Michelle Mayberry-Porter.

LPA conducted interviews, and reviewed incident reports and resident records.

It was alleged that during the incident when resident (R1) was having an aggressive behavior on 7/23/23, staff (S1) stated she's going to throw a chair to R1.

LPA interviewed 5 stafff including S1. Although S1 stated she grabbed a chair, S1 denied saying she'll throw the chair to R1. S1 stated she grabbed a chair to place in between herself and R1 in the event R1 comes around and hit her.
.....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240229112553
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: JAY MAHLER RECOVERY CENTER
FACILITY NUMBER: 019200656
VISIT DATE: 03/07/2024
NARRATIVE
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One of the other 4 staff interviewed stated hearing S1 saying she'll throw a chair to R1. The other 2 staff were not present during the time of the commotion. The other staff who was present during the entire time of the commotion stated not hearing S1 saying she'll throw a chair to R1,

Based on information obtained, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5