075601508-2-28-2022-15-AS-KHOS-CCRVAJ-20220322161600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601508
Report Date: 02/28/2022
Date Signed: 02/28/2022 06:08:09 PM

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
12/24/2020 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20201224094541

FACILITY NAME:	CORTONA PARK		FACILITY NUMBER:	075601508
ADMINISTRATOR:	AGUSTIN SAMANIEGO		FACILITY TYPE:	740
ADDRESS:	150 CORTONA WAY		TELEPHONE:	(925) 240-0733
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	150	CENSUS: 106	DATE:	02/28/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Sharon Monck, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Illegal eviction.
Staff did not allow resident to use telephone.

INVESTIGATION FINDINGS:

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On this day 2/28/2022, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to deliver findings on the above allegations. 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; 30 days eviction notice to R1.

...Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
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)

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Control Number 15-AS-20201224094541

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
	VISIT DATE: 02/28/2022

NARRATIVE

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LPA conducted interview and records review. Based on interview with S1, R1’s new physician’s report from October 2020 stated that R1 was diagnosed with dementia. According to S1, facility issued 30 days’ notice to R1 on November 13, 2020. Facility based the 30 days’ notice from the admission agreement that was signed on May 4, 2011 signed by responsible party RP1. Based on interview with S1 & S2, facility does not have a dementia care unit and R1 needs higher level of care that the facility cannot provide based on the diagnosis.

LPA has no way of verifying the allegation staff did not allow resident to use telephone R1 moved out and cannot be interviewed to verify allegation. Therefore, this allegation is unsubstantiated.

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

No deficiencies cited.

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
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

LIC9099 (FAS) - (06/04)

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