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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:54:15 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
02/23/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230223124715
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: 74DATE:
02/24/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Katherine Maningding, Assisted Living Director TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility staff are not informing resident's responsible party in a timely manner of changes in resident's medical care and condition.
INVESTIGATION FINDINGS:
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On 2/24/23 Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation for the above allegation starting at 1:15pm. LPA met with Assisted Living Director Katherine Maningding and explained the purpose of the visit.

Allegation: Facility staff are not informing resident's responsible party in a timely manner of changes in resident's medical care and condition.

LPA reviewed records including but not limited to residents’ roster, staff rosters, progress notes, identification emergency information, and contact list. LPA interviewed S1's and S2's states that they call the number that was listed on the identification emergency information, but the number does not match the number that was listed for the after hours of the POA in the identification emergency information. Therefore the allegation is SUBSTANTIATED.

Report continue on LIC 9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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-20230223124715
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: 02/24/2023
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

A copy of this report and appeal right is provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20230223124715
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: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
03/03/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement was not met as evidence by:
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LPA discussed with Katherine Maningding, Assisted Living Director POC. Katherine agree to review the regulation, and submit a self-certification, also conduct an in service training to Med-tech of reporting requirements to includes on progress note (name/ number of the whom they spoke with) to CCLD by POC date.
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Based on investigation, facility did not comply with the section cited above facility failed to notify R1's POA in timely manner about her hospitalization which poses a potential health and safety risk to the residents 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) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3