019200685-5-2-2023-15-AS-KHOS-CRLQ7U-20230507115542

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 05/02/2023
Date Signed: 05/02/2023 06:02:41 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
01/19/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220119154529

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: 77	DATE:	05/02/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	PARVEEN SINGH, Executive director		TIME COMPLETED:	06:20 PM

ALLEGATION(S):

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Personal rights. Left resident unattended.

INVESTIGATION FINDINGS:

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On 5/2/2023 at around 3:30PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegation above. LPA met with Executive Director Parveen Sighn, LPA explained the purpose of the visit.

During the course of investigation. LPA interviewed staff and resident. LPA also conducted records review.
Based on information that was gathered, incident report revealed on 1/17/2022 staff found resident (R1) on the floor. Staff called 9-1-1 for assistance.

Based on staff interview, on 1/17/2022 resident (R1) pressed his pendant to ask for assistance from staff, the staff went to check the resident and staff found R1 on the floor. Staff observed that resident (R1) had an accident. Staff stated that they check their designated residents at least every 1-2 hours.

...CONTINUE TO LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

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-20220119154529

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: 05/02/2023

NARRATIVE

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LPA conducted interview with the resident (R1), during the interview resident stated that he does not remember any incident of staff leaving resident unattended. R1 stated that staff are assisting him all the time and always checking on him.

Although the allegation may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Executive Director.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

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