019200685-8-17-2023-15-AS-KHOS-CUWNXF-20230821105103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 08/17/2023
Date Signed: 08/17/2023 01:40:59 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
02/02/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220202164755

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: 75	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Katherine Maningding, Manager on Duty Parveen Singh, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident fell while in care

INVESTIGATION FINDINGS:

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On 08/17/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with Assisted Living Director (ALD) and spoke with ED on the phone who authorized ALD to act on her behalf and sign the reports. LPA delivered the findings of above allegations to ALD. LPA explained the purpose of the visit with ED and ALD.

Allegation: Resident fell while in care
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ED, S1, S2) who stated resident (R1) displayed increasing dementia and weakness while in care. Staff stated that on several dates (01/17/22, 01/18/22, 01/29/22) staff witnessed R1 slide from his sofa and could not pull himself up without assistance. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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 4

Control Number 15-AS-20220202164755

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: 08/17/2023

NARRATIVE

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Allegation: Resident fell while in care
Investigation Finding: Unsubstantiated
Continuation...
On 01/30/22, four staff assisted R1 walk to the bathroom. Later that day, R1 had an unwitnessed fall and required a 6 person assist to lift him up from the floor and put him to a chair. Review of R1’s progress notes show staff conducted frequent safety checks on R1 and called paramedics multiple times for R1’s lift assist.

Based on interviews and record reviews which were conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident fell while in care implying lack of care and supervision by staff is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/02/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220202164755

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: 75	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Katherine Maningding, Manager on Duty Parveen Singh, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Unlawful eviction
Facility did not provide resident 30-days notice

INVESTIGATION FINDINGS:

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On 08/17/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with Assisted Living Director (ALD) and spoke with ED on the phone who authorized ALD to act on her behalf and sign the reports. LPA delivered the findings of above allegations to ALD. LPA explained the purpose of the visit with ED and ALD.

Allegation: Unlawful eviction
Investigation Finding: Unfounded
During investigation, staff (ED) stated resident (R1) was never evicted. On 01/30/22, R1 was transported to hospital ER for evaluation and treatment. On 02/02/22, R1 was discharged from the hospital and readmitted back to the facility. Continued on next page, LIC 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20220202164755

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: 08/17/2023

NARRATIVE

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Allegation: Unlawful eviction
Investigation Finding: Unfounded
Continuation...
On 02/03/22, staff (ALD, SED) held a care conference with R1’s authorized representatives (POAs) to discuss R1’s change in condition and new care plan with home health physical therapy visits. On 08/17/23, LPA observed R1 still resides at the facility during visit. This department had investigated the complaint alleging unlawful eviction. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

Allegation: Facility did not provide resident 30-day notice
Investigation Finding: Unfounded
During investigation, staff (ED) confirmed with LPA that resident (R1) was never evicted. Therefore, there was no 30-day notice issued to R1. On 08/17/23, LPA observed R1 still resides at the facility during visit. This department have investigated the complaint alleging facility did not provide resident 30-day notice. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4