<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 071440106
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:57:54 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
12/16/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201216125546
FACILITY NAME:CONCORD HOUSEFACILITY NUMBER:
071440106
ADMINISTRATOR:LEYBA, MARY ANNFACILITY TYPE:
735
ADDRESS:2301 MT. DIABLO ST.TELEPHONE:
(925) 825-4423
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:16CENSUS: 11DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Ann Leyba, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's care needs were not being met.

Illegal eviction.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/18/2021 at 02:00PM, Licensing Program Analysts (LPAs) L. Hall and J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Mary Ann Leyba, Administrator, and explained the reason for the visit.

During the course of the investigation, LPAs conducted interviews with staff, obtained and reviewed documents. LPA J. Hamilton had received email from Reporting Party (RP) giving statements of events. C1 no longer resides at the facility. For the allegation resident’s care needs were not being met. LPA obtained a copy of medical visits that was completed by staff for C1. It was noted that the last communication with C’1s podiatrist for foot care was on 05/26/2020. During interview with S1 it was stated that the facility has a podiatrist that comes into the facility to cut clients toenails, however, the facility failed to assist C1 in arrangement for services.

Continued on LIC9099.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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
Control Number 15-AS-20201216125546
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: CONCORD HOUSE
FACILITY NUMBER: 071440106
VISIT DATE: 11/18/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099.

On the allegation, illegal eviction. During interview on 11/10/2021, S1 stated that when contacted by the hospital on 09/10/2020 for discharge of C1, S1 stated “no” that facility would not take C1 back. S1 also stated after a few hours S1 telephoned the hospital again to see what medications were prescribed, but hospital was not able to give information per C1’s family and was told C1 would be discharged to the family. S1 stated she never tried to contact C1’s family to resolve issue.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

Exit interview conducted. A copy of appeal rights and this report provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20201216125546
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: CONCORD HOUSE
FACILITY NUMBER: 071440106
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
80075(a)
1
2
3
4
5
6
7
80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit a self-certification that the regulation 80075 has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.
8
9
10
11
12
13
14
Based on record review Licensee did not comply with the section cited above in arranging services, which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
Type B
11/29/2021
Section Cited
CCR
85068.5(a)(4)
1
2
3
4
5
6
7
85068.5 (a) The licensee shall be permitted to evict a client... a 30-day written notice... (4) A needs and services plan modification has been performed... and the client has been given an opportunity to relocate... This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to submit a self-certification that the regulation 85068.5 has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.
8
9
10
11
12
13
14
Based on interview Licensee did not comply with the section cited above in accepting client back into facility, which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
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: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
12/16/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201216125546

FACILITY NAME:CONCORD HOUSEFACILITY NUMBER:
071440106
ADMINISTRATOR:LEYBA, MARY ANNFACILITY TYPE:
735
ADDRESS:2301 MT. DIABLO ST.TELEPHONE:
(925) 825-4423
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:16CENSUS: 11DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Ann Leyba, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained fall while in care resulting in injury.

Staff mishandled resident while in care.

Resident suffered from dehydration while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/18/2021 at 02:00PM, Licensing Program Analysts (LPAs) L. Hall and J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Mary Ann Leyba, Administrator, and explained the reason for the visit.

During the course of the investigation, LPAs conducted interviews with staff, obtained and reviewed documents. LPA J. Hamilton had received email from Reporting Party (RP) giving statements of events. C1 no longer resides at the facility. For the allegation, resident sustained unexplained fall while in care resulting in injury. LPAs reviewed medical notes from facility which stated C1 was taken to her primary physician on 07/28/2020 and examined the same day. Based on interviews and documentation staff denies knowledge of C1 falling as a result of staff neglect or supervision.

Continued on LIC9099.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20201216125546
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: CONCORD HOUSE
FACILITY NUMBER: 071440106
VISIT DATE: 11/18/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099.

On the allegation, staff mishandled resident in care. Based on record review and interviews staff was trying to redirect C1 during the incident on 09/05/2020. S1 stated C1 was being aggressive with other residents. Record review indicated C1 was transported to the emergency room at John Muir per C1’s primary physician and Concord police suggestion.

On the allegation, resident suffered from dehydration while in care. Based on record review C1 did not require any special monitoring of water intake per medical records. Staff interviews indicated C1 had a good appetite and would let you know if she wishes to have anything.

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

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5