071441172-5-21-2021-15-AS-KHOS-CASKZM-20220118072055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 071441172
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:41:12 PM

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
01/06/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20210106122959

FACILITY NAME:	DANVILLE HOME FOR SENIORS		FACILITY NUMBER:	071441172
ADMINISTRATOR:	JAQUIAS, AURORA FE		FACILITY TYPE:	740
ADDRESS:	44 DUBOST COURT		TELEPHONE:	(925) 837-5170
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS: 4	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Aurora Jaquias, Administrator/Licensee		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to provide refund

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/21/2022 starting at 1:00pm, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation while at the facility for another matter. LPA met with Administrator, Aurora Jaquias and explained the purpose of the visit.

During the course of the investigation, LPA collected documents and interviewed Administrator. Based on interview with S1, R1 passed away on 12/22/2019 and properties were removed the following day on 12/23/2019. Record review shows a check was issued to R1's responsible party on 1/6/2021.

Based on LPA's interview 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, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of Appeal Rights and this report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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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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
01/06/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20210106122959

FACILITY NAME:	DANVILLE HOME FOR SENIORS		FACILITY NUMBER:	071441172
ADMINISTRATOR:	JAQUIAS, AURORA FE		FACILITY TYPE:	740
ADDRESS:	44 DUBOST COURT		TELEPHONE:	(925) 837-5170
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS: 4	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Aurora Jaquias, Administrator/Licensee		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights
Facility failed to meet residents needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/21/2022 starting at 1:00pm, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation and deliver findings for the above allegation while at the facility for another matter. LPA met with Administrator, Aurora Jaquias.

During the complaint investigation on this date, LPA interviewed 3 of 4 residents and 2 staff. 3 of 4 residents stated staff provides them assistance with ADLs and staff are meeting their needs. S2 stated response times varies because staff are assisting other residents. However, S1 stated she is able to respond to residents immediately. LPA observed all residents appeared to be well groomed on 5/21/2021.

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

Exit interview conducted and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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 3

Control Number 15-AS-20210106122959

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: DANVILLE HOME FOR SENIORS	FACILITY NUMBER: 071441172
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/28/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	1569.652 Termination of admission agreement.. (c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible ...15 days after the personal property is removed.	1 2 3 4 5 6 7	Administrator agrees to review regulation and send a self-certification letter to CCL by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on record review and interview, Licensee did not comply with the regulations above. R1's personal property was removed on 12/23/2019 and a refund was not issued until 1/6/2021 which poses a potential personal rights to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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