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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200890
Report Date: 12/29/2023
Date Signed: 12/29/2023 03:39:28 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
12/22/2023 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20231222093055
FACILITY NAME:CALANDRIA RESIDENTIAL CARE HOME INCFACILITY NUMBER:
019200890
ADMINISTRATOR:WAUGH, RONDIEFACILITY TYPE:
735
ADDRESS:2457 65TH AVENUETELEPHONE:
(510) 626-4911
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:6CENSUS: DATE:
12/29/2023
UNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not notify resident’s authorized representative of resident’s ER visit.
INVESTIGATION FINDINGS:
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On 12/29/23 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Rondie Waugh, Administrator and explained the purpose of the visit.

During the course of investigation, LPA attempted to call the reporting party, but the phone number provided was disconnected. LPA interviewed 2 staff at the facility and reviewed R1’s file.

Review of R1’s file showed that the Regional Center of the East Bay is R1’s representative payee and is listed as the main point of contact. There is no contact information for any of R1’s family members including the reporting party. LPA also reviewed the Special Incident Report that was generated when 911 was called for R1 on 12/07/23. It documents that Regional Center Case Manager and CCL were notified of the 911 call and the subsequent hospitalization. ***report Continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
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 2
Control Number 15-AS-20231222093055
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: CALANDRIA RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 019200890
VISIT DATE: 12/29/2023
NARRATIVE
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***report continues from LIC9099***

Staff interviews revealed that the reporting party has had little contact with R1 since his admission to the facility on 12/21/22. Staff reported that they have never had any contact information or phone number for the reporting party. Facility staff inform the Regional Center Case Manager of changes in R1’s condition.

This agency has investigated the complaint alleging facility staff did not notify resident’s authorized representative of resident’s ER visit. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2