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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600076
Report Date: 12/06/2022
Date Signed: 12/06/2022 10:13:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
11/14/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221114123356
FACILITY NAME:HAPPY VALLEY-HOME FOR OUR PARENTSFACILITY NUMBER:
075600076
ADMINISTRATOR:ONOFREI, NICOLAEFACILITY TYPE:
740
ADDRESS:3292 WALNUT LANETELEPHONE:
(925) 284-4846
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 0DATE:
12/06/2022
ANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Damaris Onofrei, AdministratorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Facility dispensed unprescribed medication to resident
Improper Eviction
INVESTIGATION FINDINGS:
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On 12/6/22 at 9:05am, Licensing Program Analyst (LPA) C. Lin arrived an announced a subsequent complaint visit to investigate the above allegations. All residents were discharged and the census is currently zero. LPA met with Administrator and informed the purpose of visit.

Allegation: Facility dispensed unprescribed medication to resident – Substantiated
The Department has investigated this allegation and per records review and interviews and found that Administrator admitted to took medicine Ativan from resident R2 and administered to R1 while waiting for R1’s prescription 2-3 times between June and July of 2022. Administrator returned medication Ativan to R2 after receiving R1’s prescription.


Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
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-20221114123356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAPPY VALLEY-HOME FOR OUR PARENTS
FACILITY NUMBER: 075600076
VISIT DATE: 12/06/2022
NARRATIVE
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Allegation: Improper Eviction – Substantiated
The Department has investigated this allegation and per records review and interviews and found that Administrator issued a 30-day notice to residents on 11/4/22 due to business closure. Based on Title 22 California code of Regulations 87224(a)(5)(A) indicated that “The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.”

Based on information obtained, the preponderance of evidence is met, therefore the allegations above are substantiated.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan of correction were discussed with Administrator.

Exit interview conducted with Administrator, Appeal Rights, LIC9099D, and a copy this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
11/14/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221114123356

FACILITY NAME:HAPPY VALLEY-HOME FOR OUR PARENTSFACILITY NUMBER:
075600076
ADMINISTRATOR:ONOFREI, NICOLAEFACILITY TYPE:
740
ADDRESS:3292 WALNUT LANETELEPHONE:
(925) 284-4846
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 0DATE:
12/06/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Damaris Onofrei, AdministratorTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Facility did not see changes in resident's condition
Facility mismanaged resident's medication
Facility is not following Admission Agreement
INVESTIGATION FINDINGS:
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Allegation: Facility did not see changes in resident's condition – Unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that there was no additional information to indicate facility did or did not see changes in resident R1’s condition. No written record was found in care notes.

Allegation: Facility mismanaged resident's medication – Unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that no written record was found to indicate missing medication for resident R1. R1 was discharged on 11/27/22, no additional information was obtained during the course of investigation.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20221114123356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAPPY VALLEY-HOME FOR OUR PARENTS
FACILITY NUMBER: 075600076
VISIT DATE: 12/06/2022
NARRATIVE
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Allegation: Facility is not following Admission Agreement – Unsubstantiated
The Department has investigated this allegation and per records review and interviews and found that Admission Agreement indicated that facility will issue 30-day notice due to change of use of the facility, and it was signed by both Administrator and R1’s representative on 7/23/2022. Facility issued a 30-day Notice on 11/4/22 and effective on 12/5/22 was observed.

Based on observations, records review, and interviews, the above allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20221114123356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HAPPY VALLEY-HOME FOR OUR PARENTS
FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2022
Section Cited
CCR
87465(a)(5)(A)
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87465 Incidental Medical and Dental Care. (a)A plan for incidental medical and dental care shall be developed by each facility….(5) Facility staff…may assist persons with self-administration as needed… (A)Medications usually prescribed for self-administration which have been authorized by the person's physician.
This requirement is not met as evidenced by…
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Administrator agrees to review the regulation and submit self-statement to CCLD by the POC due date.
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Based on observation, record reviews, and interviews, the licensee did not comply with the section cited above, where Administrator tool R2’s medication and administered to R1 while waiting for R1’s prescription which posed an immediate health, safety or personal rights risk to persons in care.
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Type B
12/13/2022
Section Cited
CCR
87224(a)(5)(A)
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87224 Eviction Procedure. (a)The licensee may evict a resident for one or more of the reasons listed in Section(5)..
(5)Change of use of the facility. (A)The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.
This requirement is not met as evidenced by…
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Administrator agrees to submit a valid 60-day notice to CCLD by the POC due date.
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Based on observation, record reviews, and interviews, the licensee did not comply with the section cited above, where issued 30-day notice to residents due to change of use of the facility which posed a potential health, safety or personal rights 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5