075601363-6-21-2022-15-AS-KHOS-CKBMY4-20221018100056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601363
Report Date: 06/21/2022
Date Signed: 06/21/2022 05:18:52 PM

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
11/02/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20211102120039

FACILITY NAME:	CHATEAU AT POETS CORNER		FACILITY NUMBER:	075601363
ADMINISTRATOR:	MICHELLE GAILEY		FACILITY TYPE:	740
ADDRESS:	540 PATTERSON BOULEVARD		TELEPHONE:	(925) 287-8750
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	75	CENSUS: 42	DATE:	06/21/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Evelyn Valladares, Executive Director and Myrene Gaeta, Resident care director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff left resident unattended for an extended period of time
Staff did not ensure resident had adequate nutrition
Staff interfered with resident's visitation
Staff did not provide residents activities

INVESTIGATION FINDINGS:

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On 6/21/2022, Licensing Program Analyst (LPA), L. Ibo arrived unannounced to investigate and deliver complaint findings of the above allegations. LPA met with S2 and new facility Administrator Evelyn Valladares, LPA explained the reason for the visit.

During the course of investigation, LPA conducted interviews, observation and records review.

Allegation: Staff left resident unattended for an extended period of time

Based on interview and records review the staff checks residents at least every 2-3 hours to be change, repositioning purposes and to encourage residents to join activities. LPA was not able to interview R1 to verify allegation since resident already moved out from facility.

…Continue to LIC9099C…

Unsubstantiated

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: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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-20211102120039

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: CHATEAU AT POETS CORNER	FACILITY NUMBER: 075601363
	VISIT DATE: 06/21/2022

NARRATIVE

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Allegation: Staff did not ensure resident had adequate nutrition

LPA tried to interview 6 residents but all of them did not respond to questions asked. LPA observed sufficient amount of food served to residents during lunch time, LPA also observed snacks given to residents after the facility staff conducted activities. LPA observed staff offered water or juices to residents that are constantly walking around the facility. Based on records review R1 do not have special dietary needs, R1 was able to feed himself.

Allegation: Staff interfered with resident's visitation

Based on interviews, the facility has a scheduling policy for families that wants to visit the residents, facility strongly recommends following facility’s schedules and if the family member are late on their schedule the staff still accommodate the family and follow covid19 guidelines. LPA was not able to interview R1 to verify allegation since resident already moved out from facility.

Allegation: Staff did not provide residents activities

Based on interview, observation and records review, the facility have activity calendar for residents, LPA observed staff providing activities for residents , based on interview the residents who prefer to stay in their room have their own personalized activities that is being provided by the facility staff. Based on R1’s assessment, he preferred to stay in his room.

Based on all information gathered during the course of investigation, the allegations are close as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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