075601490-1-30-2024-15-AS-KHOS-D26LK3-20240205074852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601490
Report Date: 01/24/2024
Date Signed: 01/30/2024 12:56:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/27/2023 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231027155632

FACILITY NAME:	MAUREEN HOUSE		FACILITY NUMBER:	075601490
ADMINISTRATOR:	JOSE MICHAEL TORIO		FACILITY TYPE:	740
ADDRESS:	590 MAUREEN LANE		TELEPHONE:	(925) 818-6536
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Alberto Bernardino, Licensee		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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1. Staff not allowing residents to leave the facility.
2. Facility not providing activities to residents.
3. Bedridden resident not repositioned.
4. Facility retained resident who can not can not physically and mentally operate own oxygen.
5. Facility not allowing family member to visit resident.
6. Family member was not notified when resident was sent out to the hospital for procedure.

INVESTIGATION FINDINGS:

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This is an amendment to an original 9099 report issued on 1/24/24.

On 01/24/2024, at 1:00PM, Licensing Program Analyst (LPA) Lori Alexander and Licensing Program Manager (LPM) Jeremy Fong arrived unannounced to conduct complaint investigation visit for the above allegations. LPA and LPM met with Lea Robes and explained the reason for the visit. Licensee/Administrator, Alberto Bernardino, arrived approximately 2:08PM.

The following documents were obtained:

Progress Notes for R1 (09/11/2023)
Visitor Sign-In Sheet (Nov. and Dec. 2023)
Appraisal/Needs and Services Plan for R4
Updated Facility Sketch

Continue on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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 3

Control Number 15-AS-20231027155632

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAUREEN HOUSE	FACILITY NUMBER: 075601490
	VISIT DATE: 01/24/2024

NARRATIVE

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Allegation: Staff not allowing residents to leave the facility.
Unsubstantiated.

On 11/02/2023 LPA attempted to speak to RP and did not receive a return call. On 11/02/2023 LPA interviewed S1 who stated that all residents can leave the facility with their family, and on 11/02/2023 LPA interviewed R2 (found to be capable) who reported observing the residents leave the facility.

Allegation: Facility not providing activities to residents.
Unsubstantiated.

On 11/02/2023 LPA attempted to speak to RP and did not receive a return call. On 11/02/2023 LPA interviewed R2 and R3 (found to be capable) who reported that they participate in music performances; and that the facility offers games, movie nights (residents can come out to the common area, or watch Netflix films in their own rooms), opportunities to go out into the community. R2 and R3 reported that several residents decline to participate.

Allegation: Bedridden resident not repositioned.
Unsubstantiated.

On 11/02/2023 LPA attempted to speak with RP and did not receive a return call. On 01/24/2024 LPA reviewed R1s Physician's Report which does not indicate that R1 is bedridden. Further, on 11/02/2023 LPA observed R1 ambulating and moving about.

Allegation: Facility retained resident who can not can not physically and mentally operate own oxygen. Unsubstantiated.

On 11/02/2023 LPA attempted to speak with RP and did not receive a return call.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20231027155632

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAUREEN HOUSE	FACILITY NUMBER: 075601490
	VISIT DATE: 01/24/2024

NARRATIVE

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On 01/24/2024 LPA interviewed S1 and S2 who reported that R1 Requires oxygen 24/7, that Apria services the oxygen machine, and that R1s physician regularly checks on the oxygen readings. On 01/24/2024 LPA and LPM Jeremy Fong interviewed W1 (R1s conservator for health) who confirmed that R1 had home health monitoring the oxygen, that the Physician is regularly visiting R1 to confirm adequate oxygen administration, and that arrangements are being made for R1 to be admitted to hospice where an appropriately skilled professional will be handling R1 and ensure adequate oxygen administration.

Allegation: Facility not allowing family member to visit resident.
Unsubstantiated.

On 11/02/2023 LPA attempted to speak with RP and did not receive a return call. On 01/24/2024 LPA interviewed S1 who stated that the subject family member (RP) has not been denied entry to visit R1, but that on 09/11/2023 the family member became belligerent and the police were called. When the PD responded, they asked the family member if she was the POA or conservator; when RP stated "no", the PD escorted RP out of the facility. On same date, LPA observed that RP signed in to visit on 09/11/2023.

Allegation: Family member was not notified when resident was sent out to the hospital for procedure.

On 11/02/2023 LPA attempted to speak with RP and did not receive a return call. On 01/24/2024 LPA interviewed S2 who stated that R1 has a conservator (W1) for health and that is the person they called. S2 stated that W1 would be the one to notify the family. LPA reviewed R1's file and observed that R1 does have a conservator that is not a family member. LPA and LPM spoke with W1 who further confirmed being the appointed conservator.

Although the allegations may have happened or are valid, there is 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 was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

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