019200664-3-21-2024-15-AS-BFOG-D47KQJ-20240410080626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200664
Report Date: 03/21/2024
Date Signed: 03/21/2024 06:51:46 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
03/14/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240314140353

FACILITY NAME:	COLONIAL ACRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	019200664
ADMINISTRATOR:	MAGALLONES, ADELIZA R		FACILITY TYPE:	740
ADDRESS:	18905 STANDISH AVENUE		TELEPHONE:	(510) 276-0939
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	20	CENSUS: 12	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	John Ronald Olivarez/Licensee		TIME COMPLETED:	06:50 PM

ALLEGATION(S):

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Licensee not providing prompt access to or photocopies of resident (R1) records.

INVESTIGATION FINDINGS:

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At 3:45 p.m. on this day, March 21, 2024, Licensing Program Analyst (LPA) Delmundo ariived unannounced to investigate the above allegation. LPA met with Ethel David, staff, and Celeste Legazpi, facility consultant, and informed the reason for visit. LPA requested to call John Ronald Olovarez, licensee, who arrived after several minutes.

During investigation, LPA intervieed the reporting party (RP), staff (S1 and S2), R1's responsible person (FM) and licensee.

.....continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240314140353

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: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
	VISIT DATE: 03/21/2024

NARRATIVE

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RP stated several attempts were made starting from February 2, 2024 to March 5, 2024 requesting for R1's documents. Requests via mail and e-mails were made with signed authorization from FM to release the documents to RP. Phone calls were also made by RP, and licensee has not responded to the request. LPA interviewed FM who confirmed she signed the document for the release of the documents to RP.

LPA interviewed S1 and S2 who confirmed receiving calls and/or emails from RP and licensee was informed. Licensee stated he received the request but has not responded to the request and emails nor returned RP's calls.

Based on information obtained, the preponderance standard has been met, therefore the allegation of "Licensee not providing prompt access to or photocopies of resident (R1) records" is substantiated.

Deficiency is cited per 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 violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the licensee.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240314140353

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: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/04/2024 Section Cited CCR 1569.269(a)(3)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability (a) .....(3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to release the documents, and submit proof by 4/04/24.
	8 9 10 11 12 13 14	-Based on interviews, the licensee did not comply with the section above for not releasing the requested documents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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