075600757-1-27-2023-15-AS-KHOS-CNLK3E-20230131063233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600757
Report Date: 01/19/2023
Date Signed: 01/27/2023 09:43:31 AM

Unsubstantiated

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
10/17/2022 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20221017153728

FACILITY NAME:	FAMILY COURTYARD		FACILITY NUMBER:	075600757
ADMINISTRATOR:	TEJERO, NORMA		FACILITY TYPE:	740
ADDRESS:	2840 SALESIAN AVENUE		TELEPHONE:	(510) 235-8284
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	70	CENSUS: 45	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Norma Tejero, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility has bed bugs.
Facility has rodents.

INVESTIGATION FINDINGS:

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On 01/27/23 Licensing Program Analyst (LPA) L. Holmes amended report to mark findings from "Needs Further Invetigation" to "Unsubstantiated", met with ADM and signed new report.

On 01/19/23 at 09:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver complaint findings for the above allegations. LPA met with Care Staff Lenie and explained the purpose of the visit. Administrator Norma Tejero was telephoned by staff and arrived about 10 minutes later.

Based on documents received and interviews with two (2) Staff and four (4) Residents, LPA also confirmed by records and receipts that the facility had a proactive treatment plan in place for pest control with Advanced IPM before and after the above allegations. S4 requested and sent Advanced IPM Pest Control company to the facility immediately after the above allegations. A dead bed bug was recovered by the inspector in room number fourteen (#14) where Resident #1 (R1) and Resident #2 (R2) reside. S1 met with the resident council, interviewed Residents and Staff, and did not have any additional reports of bed bugs or rodents.
continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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-20221017153728

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
	VISIT DATE: 01/19/2023

NARRATIVE

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...continued from LIC9099

LPA, S1 and S3 inspected the facility; LPA observed an infrared heat tent to radiate any unseen bed bugs and saw where mouse traps were strategically placed throughout the entire facility. Upon arrival on 10/19/22, LPA observed clothing items, bedding and stuffed animals that were placed in plastic bags, and a cleaning utility cart with cleaning supplies in the hallway near the door entrance of room #14.

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.

Exit interview conducted and a copy of this report provided to Norma Tejero, Administrator.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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