075601547-12-31-2021-15-AS-KHOS-CAEPJR-20220106102158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 12/31/2021
Date Signed: 12/31/2021 03:16:40 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
10/14/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20201014123817

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: 39	DATE:	12/31/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Shani Edwards, Care Coordinator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Insufficient staff to meet the needs of the residents
Facility is not clean

INVESTIGATION FINDINGS:

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On 12/31/21 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the finding of above allegation. LPA explained the purpose of the visit with care coordinator (S1). LPA spoke to administrator (ADM) on the phone and explained the purpose of the visit to S1 and ADM who authorized S1 to act on her behalf and sign the reports.

Allegation: Insufficient staff to meet the needs of the residents
Investigation Finding: UNSUBSTANTIATED
During investigation, LPA observed sufficient staffing on10/26/2020 (2 caregivers/med tech, 2 housekeepers, 1 dietary supervisor, 2 kitchen aides and 1 administrator) at the facility providing care and supervision to 46 residents. Residents were observed calm and comfortable in their surroundings.

Continued on next page, LIC 9099-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: 12/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

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-20201014123817

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: 12/31/2021

NARRATIVE

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Allegation: Facility is not clean
Investigation Finding: UNSUBSTANTIATED
During investigation, LPA observed several COVID-19 signages, disinfectants, sanitizers in the front/main entrance, hallways and common areas. LPA toured 4 residents' units with bathrooms. LPA observed residents' floors, walls and bathrooms/toilets appeared to be clean and in good repair. LPA observed residents comfortably resting inside their apartment. LPA did not observe any signs of smeared fecal matter on the walls or floors.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

LIC9099 (FAS) - (06/04)

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