075601547-10-29-2024-15-AS-KHOS-DAQREK-20241105115740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:01:41 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
10/21/2024 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20241021101209

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:	10/29/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Shani Edwards		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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9

Facility staff refused to accept resident back into care from hospital.

INVESTIGATION FINDINGS:

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On 10/29/2024 at 9:00 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge conducted an unannounced complaint visit. Upon arriving, the LPAs explained the purpose of the visit to Administrator (ADM) Shani Edwards.

The complaint alleges that facility staff refused to accept resident back into care from hospital. The LPAs interviewed the ADM and reviewed documentation for Resident R1. The data collected from those sources supported the actions of the staff not to accept R1 as resident in the facility.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove them; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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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