075601547-11-1-2023-15-AS-KHOS-CY2Q68-20231129105306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:52:21 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
10/31/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231031160632

FACILITY NAME:	COUNTRY PLACE ASSISTED LIVING		FACILITY NUMBER:	075601547
ADMINISTRATOR:	RICHARDSON, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1715 OLIVE LANE		TELEPHONE:	(925) 778-5000
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	49	CENSUS: 41	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Shani Edwards, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Residents were left unsupervised while in care

INVESTIGATION FINDINGS:

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On 11/01/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit , met with administrator (ADM1) and delivered investigation finding to ADM. LPA explained the purpose of the visit with ADM1.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, emergency/disaster plans, incident report.

Continued on next page, LIC 9099-C

Substantiated

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: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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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Control Number 15-AS-20231031160632

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: 11/01/2023

NARRATIVE

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Allegation: Residents were left unsupervised while in care
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident records. Witness (W1) confirmed with LPA that on 10/31/23 at 4AM the fire department responded to a fire alarm which has been activated at the facility for 30 minutes. When fire responders arrived, they opened the front gate with a key and a resident opened the front entrance of the facility.

Fire responders stated no staff was awake and on hand to actively supervise the residents. W1 stated they forced opened the office and called the administrator (ADM) who rushed to the facility and arrived around 5:30AM. Staff (S1, S2) were found by police and fire responders sleeping in their cars at the parking lot. Review of incident report dated 10/31/23 confirmed that staff (S1, S2) were asleep inside their cars at the parking lot while on night shift and were not inside the facility when the fire alarm was set off by a resident at 4AM. FIre alarm was blaring at the facility for 30 minutes and was deactivated by fire responders when they arrived at 5AM. ADM stated all residents were safe and no injuries were observed. ADM1 stated S1 was terminated 10/31/23 due to negligence and S2 was placed on unpaid leave while facility schedules mandatory in-service staff retraining on proper care and supervision of residents while on duty.

Based on the department’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 residents were left unsupervised while in care was found to be substantiated.

Deficiency is 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 copy of report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20231031160632

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: 11/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/10/2023 Section Cited CCR 87415(a)(2)	1 2 3 4 5 6 7	In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes	1 2 3 4 5 6 7	By POC due date, administrator agreed to complete and submit to CCL staff re-training certifications regarding night shift supervision (one staff awake & on duty with one staff on call capable to
	8 9 10 11 12 13 14	This requirement was not met as evidenced by unsupervised residents during a fire alarm which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14	respond within 10 minutes) in compliance with Title 22 Section 87415 (a)(2).
	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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

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