<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 01/24/2025
Date Signed: 01/24/2025 01:32:35 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
01/17/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250117103258
FACILITY NAME:MORNINGSTAR SENIOR LIVING OF HAYWARDFACILITY NUMBER:
019200922
ADMINISTRATOR:HENRY, CAYIAFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:170CENSUS: 99DATE:
01/24/2025
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Gabriella Johnson/Wellness DirectorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not responding to resident's (R1) responsible person.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, 01/24/2025 at 11:55 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10 day initial complaint investigation for the above allegation above. The front desk staff stated the Interim Executive Director (IED) Rosana Frias is not at the facililty. LPA called and spoke with IED over the phone, and explained the reason for the visit. IED gave permission to have the Wellness Director Gabriella Johnson to sign and receive this report.

LPA conducted interviews with staff and obtained copies of R1's Admission Agreement and document showing R1's move-out date.

It was reported that R1's family member (FM) has been reaching out to staff (S1) and facility's corporate office since May 2024 regarding refund and no one returned FM's call.

.......continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
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 4
Control Number 15-AS-20250117103258
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: MORNINGSTAR SENIOR LIVING OF HAYWARD
FACILITY NUMBER: 019200922
VISIT DATE: 01/24/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Review of email communication between staff (S1) and FM showed FM has been following-up on the refund. Email threads between FM and S1 showed FM has been following-up since September 2024. On 1/03/25, FM sent another email to S1 stating FM was having issues with S1 getting back to FM and that S1 was asked for the best way to contact S1 which S1 said via email. On 1/04/25, S1 responded to FM stating the ED who was included on the previous emails no longer work at the facility but will have the IED give FM a call on 1/06/25.

LPA interviewed the IED who stated though she is aware of the refund issues, she does not know the details. IED stated she didn't call nor send email to FM.

Based on information obtained, the preponderance of evidence standard has been met, therefore, the allegation is substantiated.

Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the IED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250117103258
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: MORNINGSTAR SENIOR LIVING OF HAYWARD
FACILITY NUMBER: 019200922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2025
Section Cited
CCR
87468.1(a)(9)
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities
(a) .......(9) To have communications to the licensee from their representatives answered promptly and appropriately.

-This requirement is not met as evidenced by
1
2
3
4
5
6
7
The IED stated she'll communicate with R1's responsible person. Proof to be submitted by 2/07/25.
8
9
10
11
12
13
14
--Based on document review and interviews, the licensee did not comply with the section above in not responding to R1's responsible person.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4