019200685-8-24-2023-15-AS-KHOS-CV5LUH-20230828090357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 08/24/2023
Date Signed: 08/24/2023 07:36:48 PM

Unsubstantiated

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
10/01/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211001153104

FACILITY NAME:	CAREFIELD CASTRO VALLEY		FACILITY NUMBER:	019200685
ADMINISTRATOR:	PARVEEN SINGH		FACILITY TYPE:	740
ADDRESS:	19960 SANTA MARIA AVE		TELEPHONE:	(510) 582-2765
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	116	CENSUS: 73	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jenny Young/Lifestyle (Activity) Director		TIME COMPLETED:	07:40 PM

ALLEGATION(S):

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-Resident (R1) is not ambulated by staff as required.

-Facility failed to meet resident’s care needs.

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 Lifestyle (Activity) Director Jenny Young, and informed the purpose of visit. LPA spoke with Executive Director Parveen Singh over the phone who authorized Jenny Young to sign and receive this report.

During the course of investigation, LPA obtained copies of resident rosters and staff schedule. LPA reviewed residents' records and obtained copies of the following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; Pre-placement Appraisal; Appraisal/Needs and Services Plan; home health visit log & notes, care notes; facility notes. LPA conducted interviews on 10/06/21 and 8/24/23.

....continued on 9099C

Unsubstantiated

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: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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

Control Number 15-AS-20211001153104

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: 08/24/2023

NARRATIVE

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Page 2

Allegation: Resident (R1) was not ambulated by staff as required.
LPA interviewed 5 staff. One (1) out of 5 staff stated that R1's physical therapist wanted R1 to be walked but sometimes R1 refused. Four of the 5 staff stated they assist residents in walking, however, there are times when residents refuse. One the 5 staff stated she never walk resident if resident came from rehab or Skilled Nursing Facility and resident has broken bones.

LPA interviewed R1's personal caregiver who stated she never observed staff walked R1. The personal caregiver of other resident was also interviewed who stated that when she needs help in assisting the resident she's hired for, the caregiver assists.

Three out of 4 residents interviewed stated they can walk on their own.

LPA was not able to get information from R1.

Based on information gathered and LPA unable to obtain information from R1, the allegation of R1 was not ambulated by staff as required is closed as 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.

.......continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20211001153104

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: 08/24/2023

NARRATIVE

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Page 3

Allegation: Facility failed to meet resident’s care needs.
It was alleged that resident (R1) was not kept clean and left in wet, soiled diapers. The reporting party further stated that R1 was observed in soiled clothing and left in wet diapers on multiple occasions.

LPA interviewed 5 staff, 4 residents, two personal caregivers and R1's family member on 10/06/21 and 8/24/23. One (1) out of 5 staff stated there were times she comes to the facility and observed residents in soiled clothing and wet diapers. One of the personal caregivers stated she observed R1 twice in soiled clothing and wet diaper, while the other personal caregiver stated she never observed the resident she's assisting and other residents in soiled clothing or wet. Four of the residents interviewed stated its either they don't need assistance in changing clothes and diaper while 1 stated the personal caregiver assist. The 3 residents stated they never observed other residents soiled and/or wet. R1's family member stated she never observed R1 in soiled clothing or wet diaper.

During one of the visits, although LPA was not able to obtain information from R1, LPA observed R1 with no smell of urine and R1's clothing clean.

Based on information gathered and LPA unable to obtain information from R1, the allegation of facility failed to meet resident’s care needs is closed as 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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