075601425-8-29-2023-15-AS-KHOS-CVKQGY-20230911121020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601425
Report Date: 08/29/2023
Date Signed: 08/29/2023 04:00:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/14/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220114083251

FACILITY NAME:	CRUSE HOUSE ALOHA		FACILITY NUMBER:	075601425
ADMINISTRATOR:	REYES, VIRGIL T.		FACILITY TYPE:	740
ADDRESS:	1850 MARINA COURT		TELEPHONE:	(925) 338-2056
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 6	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Michael Bryan Manarang, Caregiver		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility failed to meet resident's needs
Facility is in disrepair
Facility failed to provide a safe and comfortable environment

INVESTIGATION FINDINGS:

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On 8/29/23 at 12:40 PM, Associate Governmental Program Analyst (AGPA) L. Francisco and Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct complaint investigation and deliver findings for the above allegations. AGPA and LPA met with Caregiver, Michael Bryan Manarang and explained the purpose of the visit.

During the course of the investigation, AGPA L. Francisco obtained information, reviewed records, collected documents, interviewed staff and resident.

REPORT CONTINUES ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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 6

Control Number 15-AS-20220114083251

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CRUSE HOUSE ALOHA	FACILITY NUMBER: 075601425
	VISIT DATE: 08/29/2023

NARRATIVE

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Allegation: Facility failed to meet resident's needs
Based on information obtained by complainant, residents are left in soiled diaper at an extended period of time and glucose levels were not being checked by staff. Based on interview with 2 staff, 2 of 2 staff stated that residents are checked anywhere from 2-3 hours or as needed. 3 of 3 residents stated staff check on them and assists them when needed. On 8/29/23, AGPA and LPA reviewed Blood Pressure and Blood Glucose Daily Record for the month of August 2023 and observed R2's glucose level was not performed 8/6/23, 8/17/23, 8/23/23 and 8/24/23.

Allegation: Facility is in disrepair
On 1/19/22, AGPA L. Francisco observed facility's central heating and air conditioning was in disrepair. S3 confirmed during AGPA's visit that the central heating and air conditioning was in disrepair in the left wing.

Allegation: Facility failed to provide a safe and comfortable environment
Based on records obtained on 2/17/22, W1 measured the room temperature in two residents room at 63 and 64 degrees F.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted with Caregiver. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/14/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220114083251

FACILITY NAME:	CRUSE HOUSE ALOHA		FACILITY NUMBER:	075601425
ADMINISTRATOR:	REYES, VIRGIL T.		FACILITY TYPE:	740
ADDRESS:	1850 MARINA COURT		TELEPHONE:	(925) 338-2056
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 6	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Michael Bryan Manarang, Caregiver		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility has an infestation of bugs
Facility withholds resident's mail
Facility is operating outside the scope of their license capacity.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 15-AS-20220114083251

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CRUSE HOUSE ALOHA	FACILITY NUMBER: 075601425
	VISIT DATE: 08/29/2023

NARRATIVE

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Allegation: Facility withholds resident's mail
Based on interview with 3 residents, 3 of 3 residents stated no one is sending them any mail to receive. During an interview with 2 staff, it was revealed that residents are given their mail. If a resident is not able to open their mail, then responsible party is notified.

Allegation: Facility is operating outside the scope of their license capacity.
Based on information obtained by complainant, there are more than 6 residents living in the facility. AGPA interviewed 2 staff and 2 of 2 denied having more than the capacity allowed. During the visit on 7/28/23 and 8/29/23, there were 6 residents. No forthcoming information obtained from complainant.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Caregiver and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 15-AS-20220114083251

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CRUSE HOUSE ALOHA	FACILITY NUMBER: 075601425
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/30/2023 Section Cited CCR 87465(c)(1)	1 2 3 4 5 6 7	87465 INCIDENTAL MEDICAL AND DENTAL (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need.....to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician...	1 2 3 4 5 6 7	By POC date, Administrator will review regulation and conduct in-service training with staff, and submit a copy of self-certification of understanding and a copy of training with staff signatures to CCLD
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above by not performing R2's glucose level 8/6/23, 8/17/23, 8/23/23 and 8/24/23 which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 08/29/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) MAINTENANCE AND OPERATION (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Deficiency cleared during visit. AGPA and LPA observe heating and air conditioning is in working condition.
	8 9 10 11 12 13 14	Based observation and interview, Licensee did not comply with the regulation cited above by not repairing the heating and air conditioning which poses a potential health, safety and personal rights to persons in care.	8 9 10 11 12 13 14

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: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 15-AS-20220114083251

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CRUSE HOUSE ALOHA	FACILITY NUMBER: 075601425
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/29/2023 Section Cited CCR 87303(b)(1)	1 2 3 4 5 6 7	87303(b)(1) MAINTENANCE AND OPERATION (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).	1 2 3 4 5 6 7	Deficiency cleared during visit. AGPA and LPA observed room temperature maintained at 76 degrees F in the right wing and 75 degrees F in the left wing.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review, Licensee did not comply with regulation cited above. On 2/17/22, W1 measured room temperature in 2 residents room maintained at 63 degrees F and 64 degrees F which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6