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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 09/13/2022
Date Signed: 09/13/2022 11:30:40 AM

Unsubstantiated


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
09/12/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220912104729
FACILITY NAME:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, JENNIFERFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 35DATE:
09/13/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sherri Richardson, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not provided adequate PPE
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/13/22 at 10:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with staff (S1) and administrator (ADM). LPA explained the purpose of the visit with S1 and administrator.

During visit, LPA observed S1 wearing N95 face mask and face shield. LPA also observed 4 other staff wearing N95 face masks. S1 showed LPA sufficient supplies of PPEs (face shields, gowns, gloves, disposable shoe covers, N95 face masks, gloves) stored in the medication room cabinets. Local Public Health conducted a site visit on 08/30/22. ADM stated staff implemented LPH recommendations the same day to ensure mitigation of COVID infection at the facility.

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

No deficiencies cited. Exit Interview conducted and a copy of this report provided.
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: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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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