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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201146
Report Date: 07/16/2024
Date Signed: 07/16/2024 08:30:14 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
07/11/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240711153226
FACILITY NAME:ANASTASIAFACILITY NUMBER:
019201146
ADMINISTRATOR:MAHLER, OCTAVIANFACILITY TYPE:
740
ADDRESS:3646 EAST AVENUETELEPHONE:
(510) 692-7785
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 6DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:TIME COMPLETED:
08:15 PM
ALLEGATION(S):
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Staff is not fingerprint cleared.

Unqualified staff administered medications to residents.
INVESTIGATION FINDINGS:
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On 07/16/2024 around 05:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and deliver the findings for the above allegations. LPA met with Anika Brown, Staff and explained the reason for the visit. S4 was telephoned and stated that her shift had just ended and she could email any documents needed.

Allegations:
Staff is not fingerprint cleared.
Unqualified staff administered medications to residents.
SUBSTANTIATED

During the course of the investigation and visit, LPA toured the facility, reviewed a sample of three Staff (S1, S2 and S3) files. LPA requested the file for (S4), Medication Log, Current Personnel Report (LIC 500) and Resident Roster.
Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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 3
Control Number 15-AS-20240711153226
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: ANASTASIA
FACILITY NUMBER: 019201146
VISIT DATE: 07/16/2024
NARRATIVE
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...continued from LIC 9099.

-At 5:25 PM, LPA spoke to S4 who stated that she was helping the Licensee and the Licensee was not available at this time. There is not an LIC 308 available. S4 does not have any criminal record clearance on file and is not associated to the facility in Guardian; S4 stated that she/he gave the information to the Licensee but Licensee is unavailable.
-At 6:55 PM, S4 stated that he/she had been working at the facility for about two (2) weeks.
-At 6:55 PM, LPA reviewed personnel records for (S1, S2, and S3); There was not a file present for S4.
-At 7:07 PM, Sample review of C1's Medication Administration Record was not dated or signed by the staff who administered the medication. S2 stated that S4 gives out the medication; S4 is not associated to the facility.
-At 7:00 PM, Staff (S1 and S2) New Employee Training records and Certificate of Completion did not include adequate training hours for administration of medication. There was not a file present for S4.

Based on information obtained, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within a 12 month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided to Anicka Brown, Staff.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240711153226
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: ANASTASIA
FACILITY NUMBER: 019201146
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2024
Section Cited
CCR
87411(g)(1)
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87411 Personnel Requirements - General (g)...Prior to employment or initial presence...(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations...
-This requirement is not met as evidenced by:
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Licensee to submit proof to CCLD by POC date by reading the regulations and self certify. Submit proof that S4 has criminal background clearance and is associated to the facility.
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-Based on interviews and observation, the licensee did not comply with the section above by not associating S4 to the facility.
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Type A
07/19/2024
Section Cited
HSC
1569.629(a)(2)
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1569.69 Employees assisting residents with self-administration of medication; training requirements (a)...facility who assists residents...(2)...15 or fewer persons... six hours of initial training...two hours of hands-on shadowing training...
-This requirement is not met as evidenced by:


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Licensee to submit proof to CCLD by POC of medication training for all staff that assist residents with self-administration of medication.
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-Based on interviews, observation, and record review, the licensee did not comply with the section above by providing medication training to staff that assist residents with self-administration of medication.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3