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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 11/24/2021
Date Signed: 11/24/2021 03:16:01 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
11/17/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211117110613
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: 40DATE:
11/24/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shani Edwards, staffTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff are falsifying COVID vaccination records
INVESTIGATION FINDINGS:
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13
On 11/24/21 at 2:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, gathered information relevant to the allegation and delivered the investigation finding to staff (S1) and administrator (ADM). LPA explained the purpose of the visit with S1 and ADM.

S1 gave a random sampling of COVID-19 vaccination cards (8) to LPA during visit. Based on record reviews and observation, each card contained the product name/Manufacturer lot number, date of 1st dose/2nd dose and clinic site.

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. Exit Interview conducted and a copy of this report provided to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
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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