019200664-11-17-2021-15-AS-KHOS-C9BPZ6-20211202104502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200664
Report Date: 11/17/2021
Date Signed: 11/17/2021 05:59:29 PM

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
11/05/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20201105144329

FACILITY NAME:	COLONIAL ACRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	019200664
ADMINISTRATOR:	SARAH MAY BALINGIT		FACILITY TYPE:	740
ADDRESS:	18905 STANDISH AVENUE		TELEPHONE:	(510) 276-0939
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	20	CENSUS: 17	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	John Ronald Olivarez/Licensee		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not ask permission or notify the authorized representative (AR) prior to resident (R1) seeing the house doctor.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegation. LPA met with John Ronald Olivarez, licensee, and informed the purpose of visit. LPA also met with Celeste Olivarez, staff-facility consultant.

During the course of investigation, LPA reviewed R1's records, obtained copies of documents and interviewed Sarah Balingit, administrator, and R1. Documents revealed R1 authorized AR to be the medical representative while R1 was recovering from stroke that R1 had on April 2012.

.... continued on 9099C .

Unfounded

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: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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-20201105144329

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: 11/17/2021

NARRATIVE

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Administrator stated R1 does not have dementia and can decide for self. R1 did not want to go to her primary care physician with AR and that they called AR several times but AR was not responding, Administrator stated that R1 had knee pain on October 2020 and when asked, R1 refused to go to the emergency and refused to have AR contacted. Facility documentations and Interview of R1 confirmed the administrator's statements. Review of R1's 2019 and 2021 Physician's Report revealed does not have dementia, able to communicate needs and able to follow instructions.

Based on interviews, records review and that AR was authorized only to be the medical representative while R1 was recovering from stroke, the allegation is closed as unfounded. A finding that a complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Exit interview conducted and copy of this report provided to Maria Dolores Floriza.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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