075601447-11-15-2022-15-AS-HHUL-CLDVHQ-20221121152731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601447
Report Date: 11/15/2022
Date Signed: 11/15/2022 02:17:56 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
03/17/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200317164454

FACILITY NAME:	LAFAYETTE RESIDENTIAL CARE		FACILITY NUMBER:	075601447
ADMINISTRATOR:	OPHELIA PEDROSO		FACILITY TYPE:	740
ADDRESS:	1300 JUANITA DRIVE		TELEPHONE:	(925) 945-6833
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94595
CAPACITY:	0	CENSUS: 4	DATE:	11/15/2022
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Ophelia Pedroso, Administrator		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Staff not following doctor's orders.

Staff's negleck/lack of supervision resulting in residents altercation and a resident sustaining injury.

Facility in disrepair

INVESTIGATION FINDINGS:

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On 11/15/2022 at 01:55PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Ophelia Pedroso, Administrator and explained the reason for the visit.

During the course of the investigation LPA interviewed Staff 1 (S1), obtained and reviewed documents for R1. On the allegation staff neglect/lack of supervision resulting in resident’s altercation and a resident sustaining injury. LPA reviewed the LIC500 (Personnel Record) and observed there were two (2) staff scheduled. S1 stated during interview that R1 and R2 had gotten into a verbal altercation while watching television and S1 intervened. S1 then went toward the kitchen and heard a noise and observed R1 on the floor. Staff called 911 for both Residents. The facility reported the incident and sought medical attention, therefore there was supervision present and there was not any neglect.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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-20200317164454

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: 11/15/2022

NARRATIVE

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Continued from LIC9099.

Based on the allegation facility not following doctor’s order. The Reporting Party (RP) stated that R1’s blood sugar was not taken. Per Regulation “87628 Diabetes” the licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing. Therefore, the staff was not able to perform the glucose testing on any resident.

Based on the allegation facility in disrepair, during interview with RP it was stated that there was only one (1) working shower for six (6) residents. LPA A. Delmundo conducted a tele-visit interview with Staff 2 (S2) on 3/27/2020. LPA A. Delmundo instructed S2 to turn on both showers and sinks in each bathroom and both were operating. S2 stated one shower had been broken on and off due to a resident breaking the control valve, but there was always one (1) working shower. Facility had one bathtub/shower operating which the regulation requires. Therefore, the facility complied.

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

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC9099 (FAS) - (06/04)

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