075601547-4-7-2021-15-AS-HHUL-BZVUYT-20210408160028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 04/07/2021
Date Signed: 04/07/2021 01:51:43 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
10/25/2019 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191025124543

FACILITY NAME:	COUNTRY PLACE ASSISTED LIVING		FACILITY NUMBER:	075601547
ADMINISTRATOR:	RICHARDSON, SHERRY		FACILITY TYPE:	740
ADDRESS:	1715 OLIVE LANE		TELEPHONE:	(925) 778-5000
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	49	CENSUS: 45	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Carlida Racy, Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Facility staff does not meet training requirements

INVESTIGATION FINDINGS:

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On 4/7/2021 at 1:25PM Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegation. LPA G. Luk spoke with Administrator, Carlida Racy and explained reason for the tele-visit. LPA explained due to the present shelter in place order by the Governor, delivering complaint findings is being done over video conference.

During the course of investigation, LPA reviewed training documents for 3 staff. LPA confirmed with Administrator that the training documents provided included initial training, CPR & First Aid cards, and annual training for 2019. After reviewing the documents, LPA found that the 3 staff did not meet the required 40 hours of initial training and 20 hours of annual training.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.
Exit interview conducted. A copy of report and appeal rights will be emailed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

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 4

Control Number 15-AS-20191025124543

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/13/2021 Section Cited HSC 1569.625(b)	1 2 3 4 5 6 7	Staff training; legislative findings; contents. ...staff members...who assist residents with personal activities of daily living to receive appropriate training...consist of 40 hours...additional 20 hours annually	1 2 3 4 5 6 7	Administrator has agreed to submit a written statement that the facility will review current initial training and annual training to meet the requirements of 40 hours of initial training and 20 hours of annual
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above regarding staff training which poses a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14	training for all current and future staff. Administrator will submit the written statement by POC date.
	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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
10/25/2019 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191025124543

FACILITY NAME:	COUNTRY PLACE ASSISTED LIVING		FACILITY NUMBER:	075601547
ADMINISTRATOR:	RICHARDSON, SHERRY		FACILITY TYPE:	740
ADDRESS:	1715 OLIVE LANE		TELEPHONE:	(925) 778-5000
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	49	CENSUS: 45	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Carlida Racy, Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Lack of supervision - Resident was on the floor for a period of time.
Facility failed to safeguard residents personal valuable
Facility failed to meet resident's medical and dental needs

INVESTIGATION FINDINGS:

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On 4/7/2021 at 1:25PM Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegations. LPA G. Luk spoke with Administrator, Carlida Racy and explained reason for the tele-visit. LPA explained due to the present shelter in place order by the Governor, delivering complaint findings is being done over video conference.

During the course of investigation, LPA interviewed staff and resident. LPA also reviewed resident's complete file and staff schedule.

Lack of supervision - Resident was on the floor for a period of time.:
Interview with resident (R1) revealed that someone tripped him and fell. R1 stated that after pushing the call button, staff came right away to help. Staff (S1) stated there are 2 caregivers, 1 med tech, 1 house keeper, 1 maintainence, and 1 dietary staff working in the mornings. Staff schedule for caregivers and med techs does not show specific days work during the week. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20191025124543

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
	VISIT DATE: 04/07/2021

NARRATIVE

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Facility failed to safeguard residents personal valuable:
Interview with resident (R1) revealed that the facility did not lose any of R1's personal belongings. Staff (S1) stated that most residents does not have a lot of personal belongings when moving into the facility and does not keep an inventory list for the residents. S1 stated that residents' clothing have their names on them.

Facility failed to meet resident's medical and dental needs:
After reviewing resident's file, LPA observed R1 had doctors and dentist visits dated 2019 with doctor's signatures. Interview with staff (S1) revealed that there's a house doctor and dentist that would come to the facility for resident's appointments. Facility also has a driver that can take residents to their appointments.

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

Exit interview conducted and a copy of report will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4