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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201039
Report Date: 09/29/2023
Date Signed: 09/29/2023 07:23:08 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
12/29/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221229131014
FACILITY NAME:CAREFIELD PLEASANTONFACILITY NUMBER:
019201039
ADMINISTRATOR:SINGH, PARVEENFACILITY TYPE:
740
ADDRESS:4115 MOHR AVE.TELEPHONE:
(925) 461-8409
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:82CENSUS: 38DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Eunice O'Farrell, Assistant Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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On 9/29/2023 at 10:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. Upon arrival, LPA met with Assistant Executive Director, Eunice O'Farrell and explained to her the reason for the visit.

During the course of the investigation, LPA conducted interviews with staff, residents, and complainant. Resident’s physician’s report, care plan, progress notes, LIC621, reimbursement information, and email correspondence were obtained and reviewed.

LPA observed R1's progress notes stated that R1 was missing items including picture frames, clothing, iPod, and hearing aids with safety clips. LPA observed R1's LIC621 stated facility is entrusted with R1's hearing aids and safety clips. R1's hearing aids have safety clips that could be attached to R1's clothing. Interview with staff revealed that resident's belongings are usually labeled. Staff stated that hearing aids were not found and facility reimbursed R1's family for the cost of the hearing aids. (Continue LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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 5
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20221229131014
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
10/20/2023
Section Cited
CCR
87217(b)
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Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff... This requirement is not met as evidence by:
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Facility has agreed to develop a plan to better safeguard resident's belongings in the future and submit plan to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not safeguarding resident's belongings 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/29/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221229131014

FACILITY NAME:CAREFIELD PLEASANTONFACILITY NUMBER:
019201039
ADMINISTRATOR:SINGH, PARVEENFACILITY TYPE:
740
ADDRESS:4115 MOHR AVE.TELEPHONE:
(925) 461-8409
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:82CENSUS: 38DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Eunice O'Farrell, Assistant Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained an injury while in care.
Resident suffered multiple falls resulting in injuries.
Resident was not provided assistance with toileting needs
Resident was not provided assistance with showering.
Inadequate staffing to meet the needs of the residents in care.
Staff did not respond to resident's call bell.
Resident cannot easily use pull cord.
INVESTIGATION FINDINGS:
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On 9/29/2023 at 10:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. Upon arrival, LPA met with Assistant Executive Director, Eunice O'Farrell and explained to her the reason for the visit.

During the course of the investigation, the Department and LPA conducted interviews with staff, residents, and complainant. Resident’s physician’s report, care plan, progress notes, death report, incident reports, medical records, staff schedule, and pull cord record were obtained and reviewed.

Resident sustained an injury while in care.
Interview with staff revealed that R1 and R3 had an altercation on 12/28/2022 which resulted in R1 falling and sustaining an injury to the face. Staff stated that R1 was aggressive towards others and would hit residents when they got close to R1. Staff stated on 12/28/2022, R1 was trying to hit R3 with the walker when R3 past by and R3 grabbed the walker. R1 tried to yank the walker from R3 causing R1 to fall and hit her head. Staff rushed over to make sure R1 was okay while another staff called 911. (Continue on 9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20221229131014
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: 09/29/2023
NARRATIVE
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Resident suffered multiple falls resulting in injuries.
Interview with staff revealed that R1 had six falls while living at the facility in which four falls resulted in injuries or minor injuries. However, after R1’s fall on 5/22/2022, the facility raised R1’s level of care from a two to a four which increased resident checks to eight times, R1 is checked every 30 minutes due to fall risk, and fall alarms was installed in R1’s room.

Resident was not provided assistance with toileting needs
Interview with staff indicated that toileting needs are checked at least every 2 hours. Staff have not witnessed resident's toileting needs were not met.

Resident was not provided assistance with showering.
Interview with staff revealed that R1 would sometimes refuse showers and staff come back at a later time to assist R1 with showers. Staff stated when a resident refused showers, it would be documented on the progress notes.

Inadequate staffing to meet the needs of the residents in care.
LPA reviewed staff scheduled and observed AM shift have 4-5 caregivers and 1 med tech, PM shift have 4 caregivers and 1 med tech, and NOC shift have 2 caregivers and 1 med tech. Interview with staff revealed that besides the caregivers and med techs, a manager is on duty for both AM and PM shift seven days a week.

Staff did not respond to resident's call bell.
LPA reviewed a sample of resident's pull cord records and observed pull cord incidents from R1 were responded by facility staff.

Resident cannot easily use pull cord.
LPA observed R4 demonstrated how to pulled on the pull cord beside the bed and was able to pull the pull cord.

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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20221229131014
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: 09/29/2023
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5