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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600176
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:38:01 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
01/27/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220127120314
FACILITY NAME:HAILEY'S CARE HOMEFACILITY NUMBER:
075600176
ADMINISTRATOR:RIFORMO, MARIAFACILITY TYPE:
740
ADDRESS:3831 LA COLINA ROADTELEPHONE:
(510) 222-0945
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 0DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Riformo, licensee/administrator TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not provide residents with proper notification of facility closure due to COVID-19.
Staff did not provide responsible party with resident's service plan.
Staff did not provide residents with a list referral agencies.
Licensee did not provide residents with contact information for CCL/LTCO to file complaints.
INVESTIGATION FINDINGS:
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On 5/3/2023 at around 9:30AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. LPA met Administrator Maria Riformo, LPA informed her the purpose of the visit. LPA observed zero residents during the visit.

Based on interview and records review, Licensee failed to issue a proper eviction letter with complete information according to health and safety code section 1569.682 to residents or to residents’ representative.

Records review revealed that on 01/18/2022 an eviction letter was generated and provided to residents and residents representative; however, the eviction notice was incomplete, the letter was missing the following information: resident's service plan, list referral agencies, contact information for CCL/LTCO to file complaints. Based on the eviction notification the residents and representative were not given 60-days before the intended eviction.
...CONTINUE TO LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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 4
Control Number 15-AS-20220127120314
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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
VISIT DATE: 05/03/2023
NARRATIVE
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The preponderance of evidence has been met. Therefore, the allegations above are substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220127120314
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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
1569.682(a)(2)
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“(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction.
This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited.
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Based on interview and records review, licensee failed to provide proper notification to residents in care which poses a potential risk to the health and safety of resident under care.
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On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.
Type B
05/12/2023
Section Cited
CCR
1569.682(a)(2)(B)
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(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice..B) A copy of the resident’s current service plan
This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited.
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Based on interview and records review, licensee failed to provide proper eviction notification with a copy of the resident’s current service plan which poses a potential risk to the health and safety of resident under care.
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On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220127120314
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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
1569.682(a)(2)(D)
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(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice...(D) A list of referral agencies.
This requirement was not met as evidence by:

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Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited.
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Based on interview and records review, licensee failed to provide proper eviction notification with list of referral agencies which poses a potential risk to the health and safety of resident under care.
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9
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On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.
Type B
05/12/2023
Section Cited
CCR
1569.682(a)(2)(F)
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(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice..(F) The contact information for the local long-term care ombudsman...
This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited.
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Based on interview and records review, licensee failed to provide proper eviction notification with contact information for CCL/LTCO to file complaints which poses a potential risk to the health and safety of resident under care.
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9
10
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On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4