019200980-9-9-2022-15-AS-KHOS-CN6NQK-20230117094005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200980
Report Date: 09/09/2022
Date Signed: 09/09/2022 04:44:31 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
09/02/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220902143908

FACILITY NAME:	SHEPHERD HOUSE		FACILITY NUMBER:	019200980
ADMINISTRATOR:	KHAN, DOREEN		FACILITY TYPE:	735
ADDRESS:	300 SHEPHERD AVE		TELEPHONE:	(510) 303-0553
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	4	CENSUS: 4	DATE:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Doreen Khan/Administrator		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Facility abandoned resident (R1).

Staff restricted resident (R1) from receiving calls.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Doreen Khan, administrator, and informed the reason for visit.

LPA obtained copies of documents and conducted interviews.

Allegation: Facility abandoned resident (R1)
It was alleged that R1 was at the hospital and when ready to be discharged, the facility refused to take R1 back.

LPA interviewed R1's family member (FM) who indicated that the facility refused to take R1's back when R1 was to be discharged from the hospital. FM has to call the police to have the facilty admit R1 back. LPA asked and FM stated that the facility was not informed about R1 being at the hospital and to be discharged.
......continued next page

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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-20220902143908

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: SHEPHERD HOUSE	FACILITY NUMBER: 019200980
	VISIT DATE: 09/09/2022

NARRATIVE

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LPA interviewed Doreen Khan who stated that R1 was out for several days and when R1 didn't return, she filled missing person report. She never knew nor was informed by R1's family member that R1 was admitted to the hospital and that R1 was to be discharged back to the facility. She only learned about it when R1's case manager (CM) told her. Khan denied refusing to admit R1 back to the facility. Khan further stated that when R1 came back, R1 was with FM and police officer.

LPA interviewed R1's case manager (CM). CM indicated she spoke with FM who told her that R1 is taking BART to go back to the facility. CM informed Khan that R1 is coming back and Khan indicated that she will tell the staff. However, R1 didn't return on the day that R1 is suppose to return instead came to the facility the following day with FM and police officer.

Allegation: Staff restricted resident (R1) from receiving calls.
It was alleged that the facility is blocking calls.

LPA interviewed FM who stated that the administrator blocked FM's number. Khan stated that FM has been making calls, text messages anytime of the day and even at night on her personal cell phone so she blocked and unblocked FM's number but the facility phone is always available and anyone can call the facility number at any time.

LPA interviewed resident (R2). R2 stated the staff allows residents to make and receive phone calls at any time. The staff never prohibits R2 from using the facility phone.

Based on all the information gathered, the allegations of facility abandoned resident (R1) and staff restricted resident (R1) from receiving calls are closed unsubstantiated. A finding that the complaint is unsubstantiatedmeans that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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