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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200766
Report Date: 03/12/2022
Date Signed: 03/12/2022 11:42:12 AM

Substantiated


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
02/26/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210226113036
FACILITY NAME:QUEEN CARE HOMEFACILITY NUMBER:
019200766
ADMINISTRATOR:PITSCHNER, MARIANFACILITY TYPE:
735
ADDRESS:22090 QUEEN STREETTELEPHONE:
(510) 584-6922
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 6DATE:
03/12/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marian Pitschner, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Video surveillance in common areas has an audio component
INVESTIGATION FINDINGS:
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On 3/12/2022, Licensing Program Analyst (LPA) L.Ibo arrived unannounced to conduct a complaint investigation in regards to the allegation above. LPA met with Administrator, Marian Pitschner and informed her about the allegation.

During the course of investigation, LPA interviewed 1 staff (S1). Interview with staff indicated that there was video surveillance had an audio component back in March 2021, Administrator stated that former client set up the camera at the living room, other staff knew about it but did not inform the Administrator, S2 stated that the camera stayed for two weeks until the Administrator found out about it. Administrator stated that she removed the camera and talked to the staff regarding personal rights of other residents in care.

...Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
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 5
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
02/26/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210226113036

FACILITY NAME:QUEEN CARE HOMEFACILITY NUMBER:
019200766
ADMINISTRATOR:PITSCHNER, MARIANFACILITY TYPE:
735
ADDRESS:22090 QUEEN STREETTELEPHONE:
(510) 584-6922
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 6DATE:
03/12/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marian Pitschner, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility failed to administer medication to residents
Facility failed to provide hygiene supplies to residents
Residents were left unsupervised
Facility failed to drain resident's catheter
INVESTIGATION FINDINGS:
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On 3/12/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a complaint investigation regarding the allegations above. LPA met with Administrator, Marian Pitschner and informed her about the allegations.

During the course of investigation, LPA conducted records review and interview.
Facility failed to administer medication to residents: all medication administration records are completely signed by staff that medication was administered to client in care.

Facility failed to provide hygiene supplies to residents: during the visit there are sufficient hygiene supplies for clients/residents in care, hygiene supplies were observed to be available all the time, S1 stated that even though some of the hygiene supplies are locked the key is always accessible to staff, LPA observed that key is hanging by the kitchen area.
...continue to LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20210226113036
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: QUEEN CARE HOME
FACILITY NUMBER: 019200766
VISIT DATE: 03/12/2022
NARRATIVE
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Residents were left unsupervised: facility has two live in staff and one awake staff during night shift, 5 staff are working during the daytime including Administrator. Administrator stated clients are never left unsupervised.

Facility failed to drain resident's catheter: C5 had a temporary catheter in place back in January 2021 lasted for about two weeks, staff was draining the catheter bag every 2-3hrs and documented the urine output per doctor’s order.

Therefore, based on interviews and record reviews the allegations are Unsubstantiated. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20210226113036
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: QUEEN CARE HOME
FACILITY NUMBER: 019200766
VISIT DATE: 03/12/2022
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20210226113036
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: QUEEN CARE HOME
FACILITY NUMBER: 019200766
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
80072(a)(1)
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Personal Rights.
To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidence by:
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Administrator has agreed to provide documentation that the video cameras are turned off no longer at the facility and submit a copy to CCLD by POC date.
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Based on interviews, licensee failed to have video without the audio component in common areas which poses a potential personal right.
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Administrator agreed to train all staff regarding the regulation that was cited, a copy of training with staff names and signature need to be submitted to CCLD office by POC date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5