019200717-9-1-2021-15-AS-KHOS-C7QJET-20211012065939

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200717
Report Date: 09/01/2021
Date Signed: 09/01/2021 10:21:41 AM

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
08/13/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210813152137

FACILITY NAME:	BAY HARBOUR CARE HOME		FACILITY NUMBER:	019200717
ADMINISTRATOR:	RIVAS, DANIELA		FACILITY TYPE:	740
ADDRESS:	510 CENTRAL AVE		TELEPHONE:	(510) 523-0113
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94501
CAPACITY:	12	CENSUS: 3	DATE:	09/01/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Daniela Rivas, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident is being restricted from having visitors
Resident not receiving calls

INVESTIGATION FINDINGS:

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On 09/01/21 at 9:30AM, Licensing Program Analysts ( LPAs) Daisy Panlilio and Greg Clark conducted an unannounced subsequent complaint investigation to deliver the findings. LPAs explained the purpose of the visit with administrator.

Allegation: Resident is being restricted from having visitors
Investigation Finding: UNSUBSTANTIATED
Based on documentation, interviews and observations, facility staff schedules in person visitation appointments for residents' family members and friends in advance to limit residents' exposure to visitors during the pandemic as evidenced by visitation logs.

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: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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-20210813152137

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: BAY HARBOUR CARE HOME	FACILITY NUMBER: 019200717
	VISIT DATE: 09/01/2021

NARRATIVE

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House Coordinator (HC) stated visitations run from 30 minutes to an hour depending on resident availability. HC also stated residents communicate with family and friends by visits outside their window or by using Face Time or Zoom apps on the IPAD or cell phone. Residents confirm they get visits from family members, friends and home health workers. There is not a preponderance of evidence to prove the above allegation is valid. Thus, the allegation is unsubstantiated.

Allegation: Resident not receiving calls
Investigation Finding: UNSUBSTANTIATED
LPAs confirmed with residents that they are able to receive calls from family and friends. LPAs observed R1 had a working personal cell phone as well as a dedicated wireless lan line phone inside her bedroom for use when needed. She stated that sometimes she refuses to talk to family or friends when she feels tired. This department has investigated the above allegation. We have found that the complaint was unsubstantiated, meaning that 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 is unsubstantiated.

Deficiency not cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC9099 (FAS) - (06/04)

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