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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201259
Report Date: 02/13/2025
Date Signed: 02/13/2025 12:11:13 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
10/17/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20241017160414
FACILITY NAME:HEAVENLY CARE HOMEFACILITY NUMBER:
019201259
ADMINISTRATOR:NIRMALA KUPPUSAMYFACILITY TYPE:
740
ADDRESS:36857 WALNUT ST.TELEPHONE:
(925) 963-4081
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:6CENSUS: 5DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Thinn Aye, Licnesee TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not ensure that resident's diapering needs were met
Staff confiscated residents personal items
Staff do not respond to resident's call for assistance in a timely manner
INVESTIGATION FINDINGS:
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On 02/13/2025 at 09:00 AM, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with Thinn Aye, Licnesee and explained the reason for the visit.

During the course of investigation, LPA obtained information, collected documents and interviewed staff, residents and witnesses.

On the allegation: facility Staff did not ensure that resident's diapering needs were met. Based on interviews the facility staff first stated that they agreed to assist with R1's incontinence but later stated that they only change the resident at 7am and 7pm and would not assist with changes inbetween as they aranged during residents admission.

Continued on LIC 9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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 6
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
10/17/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20241017160414

FACILITY NAME:HEAVENLY CARE HOMEFACILITY NUMBER:
019201259
ADMINISTRATOR:NIRMALA KUPPUSAMYFACILITY TYPE:
740
ADDRESS:36857 WALNUT ST.TELEPHONE:
(925) 963-4081
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:6CENSUS: 5DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Thinn Aye, Licnesee TIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that there was a working telephone on the premises
Staff did not ensure that resident's were adequately fed
Staff did not ensure that resident's sacral wound was managed
INVESTIGATION FINDINGS:
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On 2/12/2025 at 09:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Thinn Aye, Licnesee .

On the allegation: Staff did not ensure that there was a working telephone on the premises
Based on observations LPA observed the phone ringing and in working condition while at the facility. LPA called the listed phone number and confirmed the number is correct.

On the allegation: Staff did not ensure that resident's were adequately fed
Based on interviews the facility does provide adequate food for the residents in care,and the residents enjoy the meals/snacks that are provided.

Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20241017160414
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: HEAVENLY CARE HOME
FACILITY NUMBER: 019201259
VISIT DATE: 02/13/2025
NARRATIVE
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...Continued from LIC9099

On the allegation: Staff did not ensure that resident's sacral wound was managed
Based on interviews with facility staff, R1 was receiving wound care from a Home Health agency. The facility staff would keep a close eye on it and call Home Health if R1's condition changed.

On the allegation facility staff are isolating resident's in their rooms. Based on interviews the facility staff would offer to bring the non-ambulatory residents to another room to socialize with each other but they would not force residents to go if they do not want too.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20241017160414
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: HEAVENLY CARE HOME
FACILITY NUMBER: 019201259
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2025
Section Cited
CCR
87625(b)(3)
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The licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This requirement is not met as evidenced by:
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The Administrator will conduct in service training with topics including incontinence care to staff and proof of correction will be submitted CCLd by POC date.
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Based on observation, the licensee did not comply with the section cited above by only assisting R1 with incontinauce care twice a day and not as needed which poses a health and safety risk to persons in care.
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Type B
02/27/2025
Section Cited
CCR
80078
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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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The Administrator will conduct in service training with topics including care and supervison to staff and proof of correction will be submitted CCLd by POC date.
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Based on observation, the licensee did not comply with the section cited above by
not assisting the residents when called for.
which poses a health and safety risk to persons in care.
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9
10
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14
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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20241017160414
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: HEAVENLY CARE HOME
FACILITY NUMBER: 019201259
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2025
Section Cited
CCR
80072(a)(3)
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2
3
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7
Every facility shall take appropriate measures to safeguard personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by:
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The Administrator purchased additional TV remote for all TVs in the facility. Deficiency cleared
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Based on observation, the licensee did not comply with the section cited above

which poses a health and safety risk to 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20241017160414
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: HEAVENLY CARE HOME
FACILITY NUMBER: 019201259
VISIT DATE: 02/13/2025
NARRATIVE
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...Continued from LIC 9099

On the allegation facility Staff confiscated residents personal items. Based on interviews the facility staff would take the television remote from the residents in one room and would not return it when it was asked for.

On the allegation facility Staff do not respond to resident's call for assistance in a timely manner. Based on interviews R1 would call facility staff to bring water or to get changed but the staff would not come and assist R1.


Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6