075601547-6-22-2021-15-AS-KHOS-C4PKS9-20210707080910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 06/22/2021
Date Signed: 06/22/2021 03:05:56 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
05/18/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210518122025

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: 44	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	02:52 PM
MET WITH:	Sherry Richardson, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide the resident with assisted hearing devices
Staff did not have a detailed summary for the resident’s doctor visits

INVESTIGATION FINDINGS:

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On 06/22/21 at 2:52PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced subsequent complaint visit to deliver the findings with administrator. LPA explained the reason for the visit with administrator.

Allegation: Staff did not provide the resident with assisted hearing devices
Investigation finding: Unsubstantiated
Based on interviews with administrator, R1, S2 and record reviews, R1 uses two hearing aid devices prescribed by the doctor. One is an audio headphone that he uses daily and the other is an inner ear canal hearing aid which is expensive. During R1's activities' sessions and whenever he requests for the inner ear canal hearing aids, staff assists R1 in wearing these devices.
Continued on next page, LIC 809-C

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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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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Control Number 15-AS-20210518122025

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: 06/22/2021

NARRATIVE

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Staff also assists R1 in changing the batteries of his hearing aids when needed. R1 is forgetful and often fails to return the hearing devices back to staff for safekeeping or he would take them out and leave them behind. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is unsubstantiated.

Allegation: Staff did not have a detailed summary for the resident's doctor visits
Investigation finding: Unsubstantiated
Review of R1's medical records show he has visited UCSF audiology and medical clinics for his hearing impairment and other issues (smoking & cancer treatments) on several dates (08/23/19, 10/16/2019, 01/13/2021).On 01/14/21, R1 had a Zoom tele-visit with his primary care physician. His doctor advised R1 to use the headphones daily and for R1 to use the more expensive inner ear hearing aids in a group setting where he is being observed and supervised by staff. Review of R1's UCSF doctor's visit discharge summary report dated 01/13/2021 show additional instructions on R1's updated medications' list, stop smoking resources and treatment for cancer. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is unsubstantiated.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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