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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601508
Report Date: 02/28/2022
Date Signed: 02/28/2022 06:21:00 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
02/28/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220228103054
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:
04:00 PM
MET WITH:Sharon Monck, Executive DirectorTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff are mistreating the residents while in care
INVESTIGATION FINDINGS:
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On 2/28/2022, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit, LPA explained the purpose of the visit with administrator Sharon Monck.

During the course of investigation, the Department obtained copies of resident roster, staff schedule, a copy of corrective action and staff roster.

LPA conducted interview and records review. Based on interview with staff, one staff (S4) received a corrective action from the manager regarding inappropriate language to resident in care.

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:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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)
Page: 1 of 2
Control Number 15-AS-20220228103054
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
HSC
1569.269(a)(1)
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1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidence by:
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Administrator agreed to conduct training of all staff with emphasis on personal rights of residents in care, training should be focusing on health and safety 1569/269(a)(1).
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Based on investigation licensee did not comply with the section cited above, S4 used inapproriate language to resident in care
which poses a potential personal rights risk to persons in care.
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A copy of topics discussed with staff signature of those in attendance will be sent to CCL by POC date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
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