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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 06/30/2022
Date Signed: 06/30/2022 01:38:22 PM

Substantiated


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
06/22/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220622082854
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: 35DATE:
06/30/2022
UNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Head lice present at the facility
INVESTIGATION FINDINGS:
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On 06/30/22 at 12:24PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator, gathered information relevant to the allegations and delivered investigation findings to administrator. LPA explained the purpose of the visit with administrator.

Allegation: Head lice present at the facility
Investigation Finding: SUBSTANTIATED
Based on interview and record reviews, administrator confirmed with LPA that resident (R1) had head and body lice infestation at the facility. After visit summary report dated 06/22/22 from the hospital also show R1 was seen in the ER for head and body lice. R1 was treated and discharged back to the facility with instructions on how to eliminate the lice with medications. The preponderance of evidence has been met. Therefore, this allegation is substantiated.
Continued on next page, LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
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 4
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
06/22/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220622082854

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: 35DATE:
06/30/2022
UNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Failed to provide a comfortable environment for residents in care
INVESTIGATION FINDINGS:
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On 06/30/22 at 12:24PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator, gathered information relevant to the allegations and delivered investigation findings to administrator. LPA explained the purpose of the visit with administrator.

Allegation: Failed to provide a comfortable environment for residents in care
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, administrator (S1) stated resident (R1) had no head or body lice when first admitted at the facility on 04/14/22. S1 stated that staff discovered R1 had head and body lice when they assisted him in shaving his beard the 3rd week of June 2022. R1 was sent to ER hospital on 06/22/22 for lice treatment and quarantined in his bedroom to prevent lice infestation with other residents. During visit, LPA observed 5 residents comfortably waiting in line for their AM medications. LPA observed they did not display any signs or symptoms of lice infestation, itchiness or skin irritation. Administrator stated no other residents were infected with lice at the facility because staff proactively quarantined R1 on 06/22/22 and treated his lice as prescribed by the hospital. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore this allegation is unsubstantiated.
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: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220622082854
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: 06/30/2022
NARRATIVE
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Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220622082854
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited
CCR
87463(b)
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The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
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By POC due date, Administrator agreed to submit to CCLD copy of staff retraining in timely addressing resident's change in condition to ensure their health & safety needs are met.
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This requirement was not met as evidenced by resident's change in condition which posed a potential health & safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4