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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200853
Report Date: 03/09/2026
Date Signed: 03/09/2026 06:51:14 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
11/07/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251107095009
FACILITY NAME:LIVERMORE CARE HOMEFACILITY NUMBER:
019200853
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1542 PERIDOT DRTELEPHONE:
(510) 825-2383
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 3DATE:
03/09/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Madeena Siddiqi, Administrator
Wesley Saguinsin, Caregiver		TIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff left resident is soiled diapers and linens for an extended period of time.
Resident's room is malodorous.
Staff do not administer medication as prescribed.
INVESTIGATION FINDINGS:
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On 3/9/2026 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with caregiver, Wesley Saguinsin and explained the purpose of the visit. Administrator, Madeena Siddiqi arrived about an hour and a half later.

During the course of investigation, LPA interviewed resident, staff, witnesses, and complainant. LPA reviewed and obtained LIC500, physician's report, care plan, emergency information, care notes, medication list, medication administration records, centrally stored medication records, and incident reports.

Staff left resident is soiled diapers and linens for an extended period of time. Interview with witness (W1) revealed that R2 has been in soiled diapers when assisting R2 with showers.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
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 6
Control Number 15-AS-20251107095009
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 CARE HOME
FACILITY NUMBER: 019200853
VISIT DATE: 03/09/2026
NARRATIVE
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Resident's room is malodorous.
LPA observed resident's rooms have strong urine smell during visits on 11/14/2025 and 1/14/2026.

Staff do not administer medication as prescribed.
LPA observed R2 has a doctor's order for Senna with instructions to take 2 tablets at bedtime from Hospice Care agency. However, LPA observed R2's Medication Administration Records (MAR) for October 2025 indicated that R2's Senna was given 1 tablet a day.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

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

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20251107095009
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 CARE HOME
FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2026
Section Cited
CCR
87625(b)(3)
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Managed Incontinence. (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for...(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator has agreed to create a plan to address managing resident's incontinence care and submit written plan to CCLD by POC date.
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This requirement is not me as evidence by: Based on interviews, licensee did not comply with the section cited above by having resident in soiled diapers which poses a potential health and safety risk to the persons in care.
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Type B
03/10/2026
Section Cited
CCR
87303(a)
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Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not me as evidence by:
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LPA observed on 3/9/2026 visit that resident's rooms did not have urine smell.

Deficiency cleared.
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Based on observation, licensee did not comply with the section cited above by having resident's room with strong urine smell which poses a potential health and safety risk to the persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20251107095009
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 CARE HOME
FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2026
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2) Once ordered by the physician the medication is given according to the physician's directions.
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Administrator has agreed to conduct in-service training to staff on medication administration. Administrator will submit staff sign-in sheet and training material to CCLD by POC date.
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This requirement is not me as evidence by: Based on record review, licensee did not comply with the section cited above by not following doctor's orders for R2's medication which poses a potential health and safety risk to the persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/07/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251107095009

FACILITY NAME:LIVERMORE CARE HOMEFACILITY NUMBER:
019200853
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1542 PERIDOT DRTELEPHONE:
(510) 825-2383
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 3DATE:
03/09/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Madeena Siddiqi, Administrator
Wesley Saguinsin, Caregiver		TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
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9
Staff do not ensure facility bathroom is free of hazards.
Resident sustained unexplained injury while in care.
INVESTIGATION FINDINGS:
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13
On 3/9/2026 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with caregiver, Wesley Saguinsin and explained the purpose of the visit. Administrator, Madeena Siddiqi arrived about an hour and a half later.

During the course of investigation, LPA interviewed resident, staff, witnesses, and complainant. LPA reviewed and obtained LIC500, physician's report, care plan, emergency information, care notes, medication list, medication administration records, centrally stored medication records, and incident reports.

Staff do not ensure facility bathroom is free of hazards.
LPA observed facility bathrooms did not have hazards. Bathroom shower chair did not have wheels; however, the shower chair was stable.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20251107095009
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 CARE HOME
FACILITY NUMBER: 019200853
VISIT DATE: 03/09/2026
NARRATIVE
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Resident sustained unexplained injury while in care.
Interview with staff and witnesses revealed that they did not observe R2 with injuries. R2's physician's report did not indicate R2 has a history of skin conditions or breakdowns.

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

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6