019200705-10-18-2023-15-AS-KHOS-CX4P34-20231030105657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200705
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:24:27 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
10/09/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231009152211

FACILITY NAME:	FULTON CARE		FACILITY NUMBER:	019200705
ADMINISTRATOR:	OCAL, GLEN		FACILITY TYPE:	735
ADDRESS:	29024 RUUS ROAD		TELEPHONE:	(510) 887-6026
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	14	CENSUS: 12	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Glen Ocal, Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not protect resident from having access to sharp object(s) resulting in self-harm
Staff not preventing resident from exposing personal body part(s)

INVESTIGATION FINDINGS:

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On 10/18/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information on the allegations and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, clients’ roster, admission agreements, physicians reports, needs & services plans, medication administration records. LPA also conducted staff (ADM, S1) and client (C1, C2) interviews during visit.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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-20231009152211

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: FULTON CARE	FACILITY NUMBER: 019200705
	VISIT DATE: 10/18/2023

NARRATIVE

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Allegation: Staff did not protect resident from having access to sharp object(s) resulting in self-harm
Investigation finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM, S1) who stated that whenever clients need to trim their beards (males) or clean their legs (females), staff give them disposable plastic razors to use which they return back to staff when done and locked back in the office. LPA observed all sharp objects were locked inside the office and kitchen drawer. LPA interviewed client (C1) who stated she bumped her head a week ago. LPA observed no razor blisters or blood on her head during visit. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not protect resident from having access to sharp object(s) resulting in self-harm and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not protect resident from having access to sharp object(s) resulting in self harm is unsubstantiated.

Allegation: Staff not preventing resident from exposing personal body part(s)
Investigation finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM S1) who stated client (C1) has lived at the facility since 01/09/2017 with mental health issues. Staff stated C1 would occasionally have episodes of hearing voices and would hurt her body because she wanted to be a man. Staff stated whenever C1 experiences these episodes, they would redirect her by calming her down and listening to her. Review of C1's medication records show staff administers C1's psychotropic medications & over the counter medications daily as prescribed by her primary care physician. LPA interviewed C2 who stated he has lived at the facility for over a year and did not witness C1 expose her body parts while at the facility. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff was not preventing resident from exposing personal body part(s) and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff was not preventing resident from exposing personal body part(s) is unsubstantiated.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

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