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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600757
Report Date: 11/04/2024
Date Signed: 11/04/2024 02:06:18 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
09/06/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230906160133
FACILITY NAME:FAMILY COURTYARDFACILITY NUMBER:
075600757
ADMINISTRATOR:TEJERO, NORMAFACILITY TYPE:
740
ADDRESS:2840 SALESIAN AVENUETELEPHONE:
(510) 235-8284
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:70CENSUS: 45DATE:
11/04/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lenie Ibe, Administrative AssistantTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not dispense medication as prescribed by physician
INVESTIGATION FINDINGS:
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On 11/4/2024 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrative Assistant, Lenie Ibe and explained the purpose of the visit.

During the course of investigation, LPA interviewed 3 residents, 3 staff, and complainant. LPA obtained and reviewed documents including physician's report, centrally stored records, MAR (Medication Administration Record), and medical records. R3's medical records and MAR revealed that R3 had a doctor's order for Clonazepam. However, R3's urine screens in June and August of 2023 indicated no Clonazepam presence.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
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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Control Number 15-AS-20230906160133
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: FAMILY COURTYARD
FACILITY NUMBER: 075600757
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2024
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by:
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Facility has agreed to conduct training for staff regarding medication administration and submit staff sign-in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not administering medications according to physician's order which poses an immediate health and safety risk to the 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2