075601490-5-5-2023-15-AS-KHOS-CU9L8A-20230731083139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601490
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:58:24 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
04/28/2023 and conducted by Evaluator Lori Alexander-Washington

COMPLAINT CONTROL NUMBER: 15-AS-20230428101559

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:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Marita Sablay, Caregiver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff not ensuring that incontinent resident is kept clean and dry.
Staff not meeting resident's care needs.

INVESTIGATION FINDINGS:

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On 05/05/2023 at 09:45 AM Licensing Program Analyst (LPA) L. Alexander and Licensing Program Manager (LPM) J. Fong conducted an Unannounced complaint investigation visit, and met with Administrator and explained the purpose of the visit.

Allegation: Staff not ensuring that incontinent resident is kept clean and dry.
Unsubstantiated.

LPA and LPM reviewed all resident files, including but not limited to the Physician's Assessments, Admission Agreements, and Appraisals; and

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: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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-20230428101559

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: 05/05/2023

NARRATIVE

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interviewed S1, S2, S3, S4, and W1 (by telephone), and R2 & R6. All staff denied that R1 had been left in a soiled diaper for an extended amount of time. All staff stated that all residents need some level of incontinent care. They reported that R1 is capable of alerting staff of a need for incontinent undergarment changing, or need for assistance for toileting. All staff reported that whether or not residents alert them, they check for changing needs every 2 to 3 hours. R6 reported that she requires incontinent care and that staff check on changing needs at least 3 times a day. W1 stated that she has visited R1 on multiple occasions and that R1 was clean and dry. W1 also stated that R1 presents as happy and expresses her like for the staff. W1 also stated her knowledge that the staff check R1 regularly. W1 reported also being the case manager for another resident and that there have been no problems pertaining to incontinent care for that other resident.

Allegation: Staff not meeting resident's care needs.
Unsubstantiated

LPA and LPM reviewed all resident files, including but not limited to the Physician's Assessments, Admission Agreements, and Needs and Services Plans. LPA and LPM interviewed S1, S2, S3, S4, and W1 (by telephone), and R2 and R6. The RP alleged that when visiting on 4/18/23, R1 was in the common areas wearing only a neglige whereby the diaper could be seen. All staff denied that any resident is allowed to walk around the home dressed inappropriately and having no knowledge of R1 walking around the home dressed only in a neglige; they also stated that R1 requires assistance while ambulating the home. R2 and R6 stated having no knowledge of this issue. W1 reported visiting the home on multiple occasions and that R1 was always clean and dressed appropriately. W1 had no knowledge of the alleged incident. No other witnesses were identified.

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: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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