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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:46:11 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
05/22/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230522162104
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: 38DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility staff did not properly manage resident's medication
INVESTIGATION FINDINGS:
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On 06/01/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit and met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

Allegation: Staff did not properly manage resident’s medication
Investigation Finding: Substantiated
During investigation, LPA confirmed with staff (S1) that resident’s (R1) prescription medications were not refilled in a timely manner resulting in R1 being without medication for 6 days. Witness (W1) also confirmed that R1’s prescription medications were not timely refilled for administration on 04/21/23 to 04/27/23.
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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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-20230522162104
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: 06/01/2023
NARRATIVE
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Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not properly manage resident’s medications was found to be substantiated.

Deficiency is 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
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20230522162104
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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87465(c)(2)
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Once ordered by the physician the medication is given according to the physician's directions…
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By POC due date, Administrator agreed to submit to CCL written self-certification that staff has read, understood and will comply with Title 22 Section 87465 regarding incident Medical and Dental care of residents.
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This requirement was not met as evidenced by staff failing to get timely refills for resident 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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
05/22/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230522162104

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: 38DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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9
Resident was illegally evicted
INVESTIGATION FINDINGS:
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On 06/01/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit and met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

Allegation: Resident was illegally evicted
Investigation Finding: Unsubstantiated
During investigation, LPA confirmed with staff (S1) that on 04/28/23, resident (R1) was sent to a psychiatric emergency hospital for treatment and evaluation. R1 was subsequently admitted to an inpatient psychiatric unit. S1 stated that facility offered to take R1 back but he did not return to the facility. Staff (S1) stated that R1 was not evicted nor given a written notice of eviction prior to his emergency visit to the hospital. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation that resident was illegally evicted did occur, therefore the allegation is unsubstantiated.

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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4