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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601447
Report Date: 11/10/2021
Date Signed: 11/10/2021 12:15:22 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
03/22/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210322103402
FACILITY NAME:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
075601447
ADMINISTRATOR:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 3DATE:
11/10/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ophelia Pedroso, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility did not provide refund to responsible party.
INVESTIGATION FINDINGS:
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On 11/10/2021 at 9:30AM, Licensing Program Analysts (LPAs), L. Hall and J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Ophelia Pedroso, Administrator and explained the reason for the visit.

On the allegation facility did not provide refund to Responsible Party. Based on record review and interviews the facility did not provide refund before the Department’s investigation. The admission agreement states R1 was admitted to facility on 02/12/2021. The total amount paid by Responsible Party was $5,000. LPA learned resident was admitted to the hospital on 02/18/2021 and personal property was removed from the facility on 02/19/2021, therefore a refund for the remaining 20 days should be provided to the Responsible Party.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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 5
Control Number 15-AS-20210322103402
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
VISIT DATE: 11/10/2021
NARRATIVE
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Continued from LIC9099.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

Exit interview conducted. A copy appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20210322103402
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited
HSC
1569.652(c)
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1569.652 (c )A refund of any fees paid in advance covering the time after... personal property has been removed from the facility shall be issued to the individual... within 15 days...This requirement was not met as evidence by:
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Administrator agreed to refund Responsible party the total amount of $3,571.40 and submit a copy of payment to CCLD by POC date.
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Based on record review Licensee did not comply with the section cited above in refunding the Responsible Party, which posed a potential health and safety 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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/22/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210322103402

FACILITY NAME:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
075601447
ADMINISTRATOR:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 3DATE:
11/10/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ophelia Pedroso, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff did not follow resident's discharge orders.
INVESTIGATION FINDINGS:
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On 11/10/2021 at 09:30AM, Licensing Program Analysts (LPAs), L. Hall and J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegation. LPAs met with Ophelia Pedroso, Administrator and explained the reason for the visit.

During the course of the investigation LPAs interviewed staff, witness, Reporting Party (RP), obtained and reviewed documents. Based on the Department’s investigation regarding the allegation staff did not follow resident’s discharge orders. LPA reviewed discharge orders from Tampico Terrace Care Center dated 02/11/2021 and orders did not indicate that an abduction pillow should be used. LPA did observe text communication between S2 and W1 dated 02/17/2021 that stated the physical therapist stated a pillow has to be between R1’s legs, however, R1 went to the doctor and never returned.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20210322103402
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
VISIT DATE: 11/10/2021
NARRATIVE
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Continued from LIC9099.

Text message further stated on 02/20/2021 an abduction pillow was being delivered on that day.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5