019200848-11-1-2023-15-AS-KHOS-CY2SHL-20231129125344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200848
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:06:49 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
10/26/2023 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231026113728

FACILITY NAME:	FREMONT RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON		FACILITY NUMBER:	019200848
ADMINISTRATOR:	KABADI, SANJAY P		FACILITY TYPE:	740
ADDRESS:	2860 COUNTRY DRIVE		TELEPHONE:	(510) 790-1645
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	40	CENSUS: 32	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Michael Sharkey, Executive Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff are not feeding resident

INVESTIGATION FINDINGS:

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On 11/1/2023 at 11:00am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Michael Sharkey, Executive Director (ED), and explained the reason for the visit.

During the investigation LPA interviewed staff, witness R1, and collected the following documents: admission agreement, assessment (8/25/2023), staff roster, resident roster, physician's report, hospice progress notes and care plan, facility progress notes, and emergency contact information, and R1's service plan.

The RP stated that staff is not feeding R1. Based on interviews R1 is able to feed herself. S4 stated dining is open from 7am to 7pm and have an all day menu.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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-20231026113728

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: FREMONT RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON	FACILITY NUMBER: 019200848
	VISIT DATE: 11/01/2023

NARRATIVE

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Continued from LIC9099.

S4 also stated that R1 is not on a restricted diet but needs the food fine chopped and the caregivers bring R1 her meals and any other food at R1's request. W1 stated during interview that R1 has a friend that was given approval to visit R1 for an hour and feed R1, but R1 is able to feed herself. R1 stated during interview that she was able to feed herself and the staff brings her food. LPA observed during interview with R1 a half eaten banana, an open container of milk, half glass of water, and R1's lunch sitting on the tray at R1's bedside. LPA also observed cookies sitting on R1's night stand. Record review of R1's physician report states R1 is able to feed herself.

Based upon the information obtained and the interviews during the investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

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