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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200766
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:13:32 PM

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
07/08/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240708110948
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: 5DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:David Lim, Licensee/ADM
Zhe "Alice" Li		TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not notify residents of a transfer of the property
INVESTIGATION FINDINGS:
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On 07/11/24 at 11:30AM, Licensing Program Analysts (LPAs) D Panlilio and A Gharachorloo conducted an unannounced visit, gathered information and delivered the investigation finding to the administrators (ADM1, ADM2). LPAs explained the purpose of the visit with ADMs.

During investigation, the department obtained the following documents from the facility – Administrators’ ARF certificates, Personnel record (LIC500), Staff training certifications, Clients’ roster with contact information, Current lease agreement with property owner, Notice of change of ownership to clients and their authorized representatives, CCLD & RCEB.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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 3
Control Number 15-AS-20240708110948
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: 07/11/2024
NARRATIVE
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Allegation: Facility did not notify residents of a transfer of property
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed clients and staff documents. Witnesses ( W1, W2) confirmed with LPAs that the Licensee/administrator (ADM1) did not go through the proper channels to timely notify Regional Center of the East Bay (RCEB), clients & their authorized representatives and Community Care Licensing (CCL) of the change in administrator, staff and transfer of property on July 1, 2024. Licensee/ADM confirmed with LPAs that the facility did not timely notify clients and their authorized representatives of the change in administration, staff and transfer of property. ADMs stated that the application for a new license (LIC200) has not been filed with Community Care Licensing for a change in ownership. ADM stated the facility is currently operating under the current ARF license with new certified direct service professionals (DSPI, DSPII).

Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility did not notify residents of a transfer of property was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of reports provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240708110948
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: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited
CCR
80061(e)(1)
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The items below shall be reported to the licensing agency within 10 working days following the occurrence: (1) The organizational changes specified in Section 80034(a), (2) Any change in the licensee's or applicant's mailing address,(3) Any change of the chief executive officer of a corporation or association, (A) Such notification shall include the new chief executive officer's name and address, (B) Fingerprints shall be submitted as specified in Section 80019(d), (4) Any changes in the plan of operation which affect the services to clients.
(f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.
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By POC due date, administrator agreed to complete and submit in-service staff training on reporting requirements in compliance with Title 22 Section 80061.
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This requirement was not met as evidenced by facility staff failing to timely and properly notify change in ownership to CCL, RCEB, clients and their authorized representatives which posed a potential health & safety risk to clients in care.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
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