<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 07/14/2026
Date Signed: 07/14/2026 12:29:18 PM

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
06/16/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260616143035
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: 46DATE:
07/14/2026
UNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff communicated inappropriately with resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/14/26 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver amended findings of above allegations. LPA explained the purpose of the visit with ADM. This is an AMENDMENT to original report dated 06/16/26.

During investigation, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, incident reports.

Continued on next page, LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
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 2
Control Number 15-AS-20260616143035
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: 07/14/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This is an AMENDMENT to original report dated 06/16/26.

Allegation: Staff communicated inappropriately with resident
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with reporting party (RP), staff (Administrator) and resident (R1) and reviewed R1’s documents. On 06/26/26, LPA interviewed ADM who stated that she failed to communicate with R1 in a timely manner on several occasions the morning of 06/01/26 because she was busy attending to other matters. However, ADM denied speaking inappropriately with R1 on 06/01/26.

LPA was unable to verify the details of the incident because there were no other witnesses when R1 tried to talk to ADM again in front of her office to the point of becoming physically aggressive. Review of written statement from R1 dated 06/26/26 showed he felt disrespected because ADM failed to communicate with him in a timely manner. ADM confirmed with LPA that she did not speak inappropriately with R1 on 06/01/26 when he was experiencing behavioral expressions.

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 that staff communicated inappropriately with resident was found to be unsubstantiated.

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2