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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 06/30/2022
Date Signed: 06/30/2022 01:35:11 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
05/19/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200519141432
FACILITY NAME:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 35DATE:
06/30/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff failed to provide adequate supervision resulting in altercation between residents
Resident was injured while in care
INVESTIGATION FINDINGS:
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On 06/30/22 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Staff failed to provide adequate supervision resulting in altercation between residents
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, incident report dated 05/08/20 show that resident (R1) was arguing with another resident (R2) at the facility over a chair on 05/05/20. R2 pushed R1 who fell on her behind. Staff (S2) reported the incident to another staff (S3) who called 911. R1 was sent to the hospital for evaluation & treatment. S3 contacted R1’s authorized representative and facility administrator about the incident.
Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
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 4
Control Number 15-AS-20200519141432
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: 06/30/2022
NARRATIVE
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R1 was diagnosed at the hospital with a hip fracture and later sent to a skilled nursing facility for rehabilitation. The preponderance of evidence has been met. Therefore, the allegation is substantiated.

Allegation: Resident was injured while in care
Investigation Finding: SUBSTANTIATED
Review of incident report dated 05/05/20 show resident (R1) suffered a hip fracture at the facility early May 2020 requiring hospitalization and rehabilitation. The preponderance of evidence has been met. Therefore, the allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
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
05/19/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200519141432

FACILITY NAME:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 35DATE:
06/30/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is malodorous
INVESTIGATION FINDINGS:
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On 06/30/22 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Facility is malodorous
Investigation Finding: UNSUBSTANTIATED
During visit on 12/31/21, LPA observed several COVID-19 signages, disinfectants, sanitizers in the front/main entrance, hallways and common areas. LPA toured 4 residents' units with bathrooms. LPA observed residents' floors, walls and bathrooms/toilets appeared to be clean and in good repair. LPA observed residents comfortably resting inside their apartments. LPA observed staff cleaning floors with disinfectant in common areas during visit. LPA observed facility was not malodorous. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore this allegation is unsubstantiated.

Exit Interview conducted and a copy of this report provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
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-20200519141432
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: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited
CCR
87411(d)(3)
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All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance. Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
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By POC due date, Administrator agreed to submit to CCLD a copy of in-service staff retraining in providing proper care and supervision to residents in care at all times.
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This requirement was not met as evidenced by staff failing to redirect residents which posed a potential health & safety risk to residents in care.
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Type B
06/30/2022
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608
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Administrator corrected deficiency during visit. Updated personnel records show sufficient staff to meet residents’ needs.
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This requirement was not met as evidenced by resident sustaining injury while in care which posed a potential health & safety risk to resident in care
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4