075601151-7-9-2021-15-AS-KHOS-C5CN5M-20210728100945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601151
Report Date: 07/09/2021
Date Signed: 07/09/2021 12:22:22 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
06/30/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210630100934

FACILITY NAME:	AG HEALTH CARE, INC.		FACILITY NUMBER:	075601151
ADMINISTRATOR:	OSHINOWO, ANTHONY		FACILITY TYPE:	740
ADDRESS:	135 LOS CERROS AVENUE		TELEPHONE:	(925) 935-9626
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 5	DATE:	07/09/2021
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Anthony Oshinowo		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility has pests & Facility is not clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) L.Ibo arrived to the facility unannounced to investigate the above allegations. LPA met with Ordell Acupan /staff and informed him the purpose visit. LPA later met with Administrator, Anthony Oshinowo.

LPA conducted inspection of residents’ bedrooms including the beds, mattresses and baseboards, residents bathrooms, kitchen area and around the facility. LPA also conducted interviews.

LPA also observed that residents’ bath tub was grey and stained, kitchen sink was stained , white microwave oven is not clean, closet floor on resident bedroom was stained, the light brown carpet on the closet was dark grey with evidence of dirt. LPA observed resident bedroom has ants crawling on the floor.

.....continueLIC9099C....

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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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Control Number 15-AS-20210630100934

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: AG HEALTH CARE, INC.	FACILITY NUMBER: 075601151
	VISIT DATE: 07/09/2021

NARRATIVE

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LPA also interviewed the Administrator and staff. Although staff interviewed stated they have not seen bed bugs, the Administrator admitted there was bed bugs at the facility couple of weeks ago. The Pest control company came to treat bed bugs and documentation was obtained by LPA. LPA personally observed ants on the floor in one of the resident's bedroom.

Based on information obtained and LPA personal observation, the allegations of facility has pest and facility is not clean is substantiated.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Administrator A. Oshinowo.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to A. Oshinowo.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210630100934

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: AG HEALTH CARE, INC.	FACILITY NUMBER: 075601151
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/23/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 (a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will clean facility and will send photo's to LPA L.Ibo on the POC date. Facility Administrator will clean bedroom with ants using appropriate pest control spray, a photo/document need to be sent to LPA on the POC date.
	8 9 10 11 12 13 14	Based on interview and inspection, the Administrator failed to ensure the facility is free of pest which poses potential health and safety risks to residents in care. LPA observed pest (ants) in resident's bedroom Administrator admitted that there were bed bugs at the facility couple of weeks ago. The facility was also not clean.	8 9 10 11 12 13 14
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	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: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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