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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201069
Report Date: 10/12/2021
Date Signed: 03/09/2023 06:27:16 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
10/08/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211008162448
FACILITY NAME:GENTLE HEART CARE SERVICES INCFACILITY NUMBER:
019201069
ADMINISTRATOR:SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 342-6740
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 3DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Alanna Spencer/AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
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Resident (R1) requires a higher level of care.

INVESTIGATION FINDINGS:
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*THIS IS AN AMENDED REPORT*
Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with staff, Claudia Martinez Marin. LPA called Alanna Spencer, administrator, who arrived after about 40 minutes. LPA informed the purpose of visit.

LPA conducted interviews and reviewed resident's (R1) file. LPA obtained copies of the following documents: LIC602 Physician's Report; conservatirship document; facility intake documents

Facility intake document indicated ongoing risks if leaving housing placement impulsively. Two staff interviewed indicated R1 leaves the facility on her own, and staff never follows R1 when R1 leaves which LPA confirmed with Alanna Spencer. Spencer statedR1 needs higher level of care and that R1 should have moved to Rehab prior to moving to Gentle Heart; however there was no vacancy at the Rehab time at the so R1 was moved directly to this facility. ...........continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
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 4
Control Number 15-AS-20211008162448
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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069
VISIT DATE: 10/12/2021
NARRATIVE
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Based on information gathered, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date may result in civil penalties.

Deficiency and plan and proof of corrections were discussed with Alanna Spencer.

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: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20211008162448
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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited
CCR
000000
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xTHIS IS AN AMENDED 809D
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Type B
10/19/2021
Section Cited
CCR
85068.4(a)(4)
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85068.4 Acceptance and Retention Limitations
(a) The licensee shall not accept or retain the following: (4) Persons who require more care and supervision than is provided by the facility.

-This requirement is not et as evidenced by:
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Administrator stated she'll be working with R1's case manager and responsible person in finding a new placement. Proof to be submitted by 10/19/2021.
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-Based on interviews and records review, the licensee did not comply with section above by accepting resident who needs higher level of 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4