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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200664
Report Date: 11/17/2021
Date Signed: 11/17/2021 06:00:24 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
03/12/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210312111649
FACILITY NAME:COLONIAL ACRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200664
ADMINISTRATOR:SARAH MAY BALINGITFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:20CENSUS: 17DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:John Ronald Olivarez/LicenseeTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not keep the facility free from pests.

Facility has inadequate record keeping.

Staff did not properly assist the resident (R1) while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with John Ronald Olivarez, licensee, and informed the purpose of visit. LPA also met with Celeste Olivarez, staff-facility consultant. Licensee left the facility.

During the course of investigation, LPA interviewed staff (S1 and S2), administrator, licensee and R1's family member (FM1). LPA also obtained copies of R1's document including but limited to Physician's Report, hospital discharge document dated March 6, 2021.

1. Allegation: Staff did not keep the facility free from pests
It was alleged that roaches were observed around R1's bed and other areas of the facility..
S1, S2, administrator and licensee indicated during interview that facility has roaches. Administrator stated that roaches came out when facility was being renovated and when flooring was dilapidated.
......continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (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)
Page: 1 of 4
Control Number 15-AS-20210312111649
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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2. Facility has inadequate record keeping
It was alleged that staff were not able to provide any details of the R1's medical situation and that S1 was not able provide R1's hospital discharge document when asked by medical transport person.
LPA interviewed S1 who stated he looked for the document and was not able to locate it.

3. Staff did not properly assist R1 while in care
It was alleged that R1 wanted to go to hospital due to abdominal pain. R1 was found in great distress at 2 a.m. on March 7, 2021 with staff reporting that R1 had been in "10 out of 10 pain" for the full afternoon and evening prior.

S1, S2 and administrator indicated that R1 was hospitalized and discharged back to the facility on March 6, 2021 in the afternoon. S1 indicated that R1 has been yelling from the time he was discharged from the hospital and they called non-emergency transport around 12:00 midnight, 1:00 pm the following day. LPA interviewed FM1 who stated that when she called R1 two, three times in evening on March 6, 2021, R1 complained of stomach pain. FM1 spoke with S2 who told FM1 that they (staff) will call non-emergency transport. FM1 stated what she did not understand was why it took 2:00 am for the responder to arrive if the staff called right after FM1 spoke with S2.

Based on the information gathered, the preponderance of evidence were met, therefore all 3 allegations are substantiated. Deficiencies are cited from Title 22 California Code of Regulations (see 9099D), Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with licensee over the phone who authorized Maria Dolores Floriza to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (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)
Page: 3 of 4
Control Number 15-AS-20210312111649
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: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
87468.2(a)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a).... elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee to revisit facility medical emergency protocol and in-service staff. Copy of in-service training with attendees signatures to be submitted by 11/18/2021.
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-This requirement is not met as evidenced by:

-Based on interviews, the licensee did not comply with the section above. R1 was in distress and pain and staff failed to call emergency in timely manner which posed personal rights risk to person in care.
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Type B
12/01/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Corrected.
Facility contracted with pest control company.
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-This requirement is not met as evidenced by:

-Based on interviews, the licensee did not comply with the section above. Facility had roaches which posed potential health and personal rights 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210312111649
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: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2021
Section Cited
CCR
87506(a)
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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
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Licensee to do the following:
1. Have all residents' records checked and ensure they are complete and in one place.
2. In-service staff.
Proof to be submitted by 12/0/2021.
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-Based on interviews, the licensee did not comply with the section above. R1's document was not located when staff tried to find it which posed potential health and personal rights risks to person 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4