075601547-5-27-2021-15-AS-KHOS-C3ZL8D-20210615083146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 05/27/2021
Date Signed: 05/27/2021 02:51:27 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
06/15/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20200615151730

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: 43	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sherry Richardson, Administrator		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff do not allow resident to use the Home Health Agency of their choice

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/27/21 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegation.

On 06/26/20, LPA interviewed ADM and R1 regarding the allegation. ADM stated that R1 was offered a Home Health agency while at the rehabilitation center. However, R1 changed her mind and decided to use Lifeguard when she returned to the facility. LPA confirmed with R1 that she authorized Lifeguard to provide her with therapy needed.

Based on LPA’s observations and interviews which were conducted on 06/26/20, 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 during this visit. Exit Interview conducted and a copy of this report provided to Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

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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