019201039-1-12-2024-15-AS-KHOS-D4MH47-20240424055128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201039
Report Date: 01/12/2024
Date Signed: 01/12/2024 05:27:19 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
03/29/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230329161525

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: 38	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Eunice O'Farrell, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff overdosed resident on medication.
Facility staff did not attend to residents in a timely manner after falling.
Facility staff leave residents in urine and feces for extended periods of time.

INVESTIGATION FINDINGS:

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On 1/12/2024 at 1:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPA met with Executive Director, Eunice O'Farrell and explained to her the reason for the visit.

During the investigation, LPA interviewed 7 staff and complainant. LPA reviewed and obtained documents including staff roster with contact information, physician's report, care plan, incident reports, medication list, MAR, discharge documents, pull cord records, and care notes.

Facility staff overdosed resident on medication.
After reviewing R7's MAR, LPA observed R7 was given medications according to doctor's orders. R7's care notes did not indicate R7 was given overdosage of medications. Interview with staff revealed that med techs followed doctor's order when given medications to R7 and denied of giving overdose of medications to R7. (Continue on 9099C...)

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: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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-20230329161525

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: 01/12/2024

NARRATIVE

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Facility staff did not attend to residents in a timely manner after falling.
After reviewing a sample of resident's pull cord records, LPA observed staff response time to pull cords is less than 16 minutes. Interview with staff indicated there hasn't been an incident where pull cord response time is an hour or more.

Facility staff leave residents in urine and feces for extended periods of time.
Interview with staff revealed that resident's diaper checks are 2-3 hours and some residents are checked more frequent. Staff stated there hasn't been an incident where resident is left in soiled diaper for an extended periods of time.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC9099 (FAS) - (06/04)

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