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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200001
Report Date: 11/03/2022
Date Signed: 11/03/2022 09:23:40 AM

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
07/20/2022 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20220720083356
FACILITY NAME:SPRINGHILL HOMEFACILITY NUMBER:
079200001
ADMINISTRATOR:REGINA D. LIMFACILITY TYPE:
735
ADDRESS:1387 SPRINGHILL DRIVETELEPHONE:
(925) 427-7870
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 6DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alma Tubianosa, CaregiverTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility did not ensure resident is using oxygen machine

Facility did not ensure resident attended follow-up medical appointments.
INVESTIGATION FINDINGS:
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On 11/3/2022 at 09:00AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegations. LPA met with Caregiver, Alma Tubianosa explained the reason for visit. Administrator, Regina Lim arrived at 9:15AM.

During the course of the investigation LPA interviewed Staff 1 (S1), Client 1 (C1), and spoke with Reporting Party (RP). On the allegation facility did not ensure resident is using oxygen machine. S1 stated that she works the night shift at the facility and that C1 refuses to use the oxygen machine. LPA observed C1 sitting and watching television without the oxygen machine. When LPA interviewed C1 he stated that he doesn’t need it. During record review it indicated on the discharge summary that the oxygen machine is to be used at night.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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 2
Control Number 15-AS-20220720083356
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: SPRINGHILL HOME
FACILITY NUMBER: 079200001
VISIT DATE: 11/03/2022
NARRATIVE
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Continued from LIC9099.

On the allegation facility did not ensure resident attended follow-up medical appointments. S1 stated during interview that C1 refuses to go to appointments. S1 tries to coerce S1 to go to appointments but he still refuses. S1 also stated there was a time where the taxi wasn’t reliable, but other means of transportation was provided. During record review LPA observed case notes that indicated on several days dating back to 2021 where C1 refused to see a doctor.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2