019201039-7-28-2022-15-AS-KHOS-CMKNJY-20221229093108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201039
Report Date: 07/28/2022
Date Signed: 07/28/2022 04:12:41 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
05/13/2022 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20220513164341

FACILITY NAME:	CAREFIELD PLEASANTON		FACILITY NUMBER:	019201039
ADMINISTRATOR:	SINGH, PARVEEN		FACILITY TYPE:	740
ADDRESS:	4115 MOHR AVE.		TELEPHONE:	(925) 461-8409
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY:	82	CENSUS: 44	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Parveen Singh, Senior Executive Director Jocelyn Sanjuan, Business Office Director		TIME COMPLETED:	04:28 PM

ALLEGATION(S):

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Facility failed to provide adequate supervision resulting in resident pushing another resident.

INVESTIGATION FINDINGS:

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On 7/28/2022 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPA met with Business Office Director, Jocelyn Sanjuan. Senior Executive Director, Parveen Singh arrived a couple hours later.

During the investigation, LPA interviewed 1 resident and 3 staff. LPA reviewed and obtained documents including staff schedule, incident report, physician's report, care plan, emergency information, and care notes for two residents.

Interview with staff revealed that R1 was asking S2 for food right outside the kitchen door. R2 got up and approached S2 to ask for water. R1 turned the walker to block R2 from going closer to the kitchen door. R2 pushed R1 lightly and said "excuse me". R1 loss balance and fell down. LPA reviewed staff schedule and observed there was 4 caregivers and 1 med tech on duty during incident. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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-20220513164341

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: CAREFIELD PLEASANTON	FACILITY NUMBER: 019201039
	VISIT DATE: 07/28/2022

NARRATIVE

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Interview with resident revealed that R2 did not remember what happened on 5/12/2022 or the incident between R1 and R2. LPA reviewed R1 and R2's records and observed both residents did not require 1:1 care and supervision.

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

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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