<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 01/21/2021
Date Signed: 01/21/2021 04:17:31 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
09/25/2020 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200925141623
FACILITY NAME:CAREFIELD CASTRO VALLEYFACILITY NUMBER:
019200685
ADMINISTRATOR:PARVEEN SINGHFACILITY TYPE:
740
ADDRESS:19960 SANTA MARIA AVETELEPHONE:
(510) 582-2765
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:116CENSUS: 33DATE:
01/21/2021
UNANNOUNCEDTIME BEGAN:
04:02 PM
MET WITH:Parveen SinghTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff used a different pharmacy to refill medications without the resident's authorization.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/21/2021, Licensing Program Analyst (LPA) Allison O’Hollaren conducted a telephone meeting and spoke with Administrator, Parveen Singh. LPA informed Administrator that due to the shelter in place order of the governor and the telework directive of management, this meeting is being conducted via telephone. The purpose of the call is to deliver finding on the above allegation.

Based on interviews conducted and records reviewed, R1 had insurance coverage with Kaiser Permanente. However, facility utilized a different pharmacy in ordering R1’s medications without authorization from R1 or R1’s Responsible Party.

Continued on 9099C.....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
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 3
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20200925141623
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: CAREFIELD CASTRO VALLEY
FACILITY NUMBER: 019200685
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
02/04/2021
Section Cited
HSC
1569.80(a)
1
2
3
4
5
6
7
A resident...or the resident's representative...shall have the right to participate in decision making regarding the care and services to be provided to the resident. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
By POC date, facility will submit a statement that an in-service review of the regulation was made with all managerial staff and includes the signatures of the attendees.
8
9
10
11
12
13
14
LPA observed that facility failed to utilize R1s insured medication provider, using an alternate pharmacy without R1s expressed consent, which poses a potential threat to the health and safety of clients in care.
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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20200925141623
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: CAREFIELD CASTRO VALLEY
FACILITY NUMBER: 019200685
VISIT DATE: 01/21/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on LPA’s interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The deficiency is cited per CCR Title 22. Failure to provide proof of correction by POC date may result in civil penalties.

Exit interview conducted and Appeal Rights provided. Due to the State's current Shelter in Place Order, a copy of this report was provided by email
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3