<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601508
Report Date: 02/28/2022
Date Signed: 02/28/2022 06:14:33 PM

Substantiated


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
12/29/2020 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20201229162812
FACILITY NAME:CORTONA PARKFACILITY NUMBER:
075601508
ADMINISTRATOR:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 106DATE:
02/28/2022
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Sharon Monck, Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not follow appropriate medical assessment procedures.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day 2/28/2022, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to deliver findings on the above allegation. LPA met and explained the purpose of the visit with Administrator Sharon Monck.

During the course of investigation, the Department obtained copies of resident roster, LIC601 Identification and Emergency Notification Information; Admission Agreement; Physician's Report; Pre-placement Appraisal.
Based on LPA’s interviews & records review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) were found to be SUBSTANTIATED. Staff S1 & S2 admitted that family of R1 signed admission agreement before conducting medical assessment.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
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 2
Control Number 15-AS-20201229162812
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: CORTONA PARK
FACILITY NUMBER: 075601508
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
87457(c)
1
2
3
4
5
6
7
87457 Pre-Admission Appraisal – General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs...
This requirement was not met as evidenced by
1
2
3
4
5
6
7
Administrator agreed that all facility staff, not limited to Sales manager, Resident Care Coordinator, Executive Director & Business Office Coordinator, that are involve with admission process will receive training regarding the regulation that was cited.
8
9
10
11
12
13
14
Based on the interview and records review, the licensee failed to ensure that the facility staff failed to complete a needs/services/appraisal for R1 prior to admission which posed a potential health & safety risk to resident in care.
8
9
10
11
12
13
14
Administrator also will need to submit self-certification document from all staff that will receive training that they read, understood and will comply with Title 22 Section 87457 Pre-Admission Appraisal.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2