019200764-2-8-2023-15-AS-KHOS-CP2SVQ-20230214131306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200764
Report Date: 02/08/2023
Date Signed: 02/08/2023 05:16:38 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
01/11/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230111123804

FACILITY NAME:	LIVERMORE VALLEY SENIOR CARE		FACILITY NUMBER:	019200764
ADMINISTRATOR:	DONG, ZHIYONG		FACILITY TYPE:	740
ADDRESS:	3356 EAST AVENUE		TELEPHONE:	(925) 447-5483
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	20	CENSUS: 6	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Elizabeth Nagy, Administrator		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Staff do not provide meals to residents timely
Staff do not allow resident to use the phone

INVESTIGATION FINDINGS:

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On 2/8/2023 at 4:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver findings in regards to the allegations above. LPA met with Administrator, Elizabeth Nagy.

During the course of investigation, LPA G. Luk interviewed 8 residents, 3 staff, and complainant. LPA obtained and reviewed physician's report.

Staff do not provide meals to residents timely
Interview with residents revealed that residents are provided with meals timely. Residents stated they are receiving three meals daily. Interview with staff indicated that breakfast is served around 8:30AM to 9AM, lunch is served around 12PM to 1PM, and dinner is served around 5PM to 5:30PM. LPA observed meal was being served during visit on 1/19/2023.
(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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-20230111123804

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: LIVERMORE VALLEY SENIOR CARE	FACILITY NUMBER: 019200764
	VISIT DATE: 02/08/2023

NARRATIVE

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Staff do not allow resident to use the phone
Interview with residents indicated majority of them have their own personal cell phones. However, residents states that they can borrow a phone from staff if needed. LPA observed each staff have a work cell phone. Interview with staff indicated that residents can borrow their work cell phones when needed.

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

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

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