075601451-4-5-2023-15-AS-YFLS-CSDVJL-20230601162856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601451
Report Date: 04/05/2023
Date Signed: 04/05/2023 01:01:01 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
02/01/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220201133529

FACILITY NAME:	KARO MINA CARE HOME		FACILITY NUMBER:	075601451
ADMINISTRATOR:	EWEDA, MONA		FACILITY TYPE:	740
ADDRESS:	2866 LARAMIE AVENUE		TELEPHONE:	(925) 551-8263
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 3	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Mona Eweda, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care
Resident's hygiene needs were not met
Resident's toileting needs were not met
Resident's grooming needs were not met
Medications are not stored appropriately

INVESTIGATION FINDINGS:

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On 4/5/2023 at 10:45 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. LPA met with Administrator, Mona Eweda and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, collected documents, reviewed records and interviewed staff and residents.

Allegation: Resident sustained unexplained injuries while in care.
Based on information obtained, resident (R1) had bruising on forearm and thighs. LPA reviewed records and did not observe documentation regarding the bruise.

REPORT CONTINUES ON 9099C

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: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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-20220201133529

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: KARO MINA CARE HOME	FACILITY NUMBER: 075601451
	VISIT DATE: 04/05/2023

NARRATIVE

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However, S1 and S2 stated if there are any bruising observed, then staff will notify resident's responsible party. LPA was unable to interview R1. Therefore, LPA was unable to prove or disprove allegation occurred.

Allegation: Resident's hygiene needs were not met
Based on interview with 2 staff, 2 of 2 staff stated residents are provided a sponge bath daily. LPA interviewed 2 residents, and 2 of 2 residents confirmed they are provided sponge bath daily. LPA observed a photo of R1 in a history of texts between S2 and R1's responsible party, and R1 appeared to be well groomed.

Allegation: Resident's toileting needs were not met
Based on interview with 2 staff, 2 of 2 staff stated residents are changed 3 to 4 times a day or as needed. R2 stated staff assists R2 with toileting.

Allegation: Resident's grooming needs were not met
Based on record review, LPA observed a photo of R1's nail and observed toe nails were long. However, S1 and S2 requested R1's responsible party to schedule an appointment with podiatrist to trim R1's toe nails. LPA observed a photo R1's finger nails were manicured. S1 and S2 stated residents finger nails and toe nails are filed, but will communicate with family to schedule for trimmings with a podiatrist.

Allegation: Medications are not stored appropriately
Based on information obtained, Lorazepam were not stored in the refrigerator. However, interview with S1 and S2 revealed that liquid lorazepam are stored in a locked container in the refrigerator. Due to conflicting information, LPA was unable to prove or disprove allegation occurred.

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

Exit interview conducted and a copy of this report provided to Administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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