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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601320
Report Date: 04/12/2023
Date Signed: 04/12/2023 12:21:23 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
04/11/2023 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20230411154803
FACILITY NAME:BELROSE CARE HOME IIIFACILITY NUMBER:
075601320
ADMINISTRATOR:JUNSAY, ROSAFACILITY TYPE:
740
ADDRESS:226 NORMANDY LANETELEPHONE:
(925) 689-8831
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
04/12/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee Rosa JunsayTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident's bed is blocked by another piece of furniture preventing passage around the room.
INVESTIGATION FINDINGS:
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On 04/12/2023 at 8:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a complaint inspection. LPA explained purpose of the visit to Caregiver Evangeline Polito, who toured facility with LPA. Licensee Rosa Junsay arrived at 10:50 AM.

At 8:15 AM, LPA observed furniture matching that sent by Complainant in resident R1's room. When asked, Caregiver Polito confirmed that it was used to block R1's exit from the bed at night. Based on the data collected by observation and interview, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED.

Deficiency cited per Title 22 California Code of Regulations is listed on the LIC9099-D. Failure to submit proof of correction (POC) 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 via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
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 2
Control Number 15-AS-20230411154803
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: BELROSE CARE HOME III
FACILITY NUMBER: 075601320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights: (3) To be free from ... interfering with daily living functions such as ... elimination.

This requirement was not met as evidenced by:
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On or before due date, Licensee shall get an updated Care Plan from R1's physician addressing her night wandering behavior.
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Based on observation and interview, the licensee blocked resident R1's ability to leave her bed to use the bathroom, which did not comply with the section cited above, 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2