<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200169
Report Date: 04/13/2023
Date Signed: 04/13/2023 01:51:15 PM

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
04/12/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20230412151908
FACILITY NAME:PROFESSIONAL ASSISTED LIVINGFACILITY NUMBER:
079200169
ADMINISTRATOR:RAY LANGIT,DARLENE ATIZADOFACILITY TYPE:
735
ADDRESS:852 CORAL DRIVETELEPHONE:
(510) 245-7234
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY:6CENSUS: 6DATE:
04/13/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lorna Nidea, CaregiverTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/13/2023 at 12:15PM, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Caregiver, Lorna Nidea and disclosed the purpose of the visit and was granted entry into the facility.. 1 Client and 2 staff were present in the facility during the delivery. The facility is a X5-bedroom, and 2 bathroom house.

ALLIGATION: Client sustained unexplained bruising while in care.
Investigation finding: UNSUBSTANTIATED

During the course of the investigation the Department interviewed 3 staff, 2 witnesses and RP LPA unable to interview C1 due to diagnosis. LPA requested & reviewed the following documents: Facility & staff roster, incident reports, Physicians report, IPP/ISP, after visit summary report, admission agreement, progress notes, appraisal needs & service plan.
CONTINUE ON LIC9099C


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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-20230412151908
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: PROFESSIONAL ASSISTED LIVING
FACILITY NUMBER: 079200169
VISIT DATE: 04/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUE FROM LIC9099

Interviews with staff, witnesses and record review revealed that C1 has self harming behaviors which increases when C1 is in pain.

Interview with W1 revealed that C1 has self harming behaviors and has recently been more self harming then normal due to pain. W1 also stated that C1 had an issue on the Day Program bus which caused bruising. Interview with W2 revealed that C1 has self harming behaviors. Interview with staff S2 and S3 also revealed that C1 has self harming behaviors and that C1 gets agitated and has recently been having more behaviors then normal. Interview with S1 revealed that C1 is easy going, has been living in the facility 15 years, has always had self harming behaviors but since January 2023 C1 has been in dental pain and has been exhibiting more self harming behaviors. S1 stated that C1 had a reaction to an IV when she was in the hospital for a week in January and is currently being treated by the wound clinic. S1 also stated that C1 got C1 right arm caught in the Day Programs van door while they were dropping C1 off at the facility, The Day Program called for emergency services and C1 was transported to the hospital.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview and copy of report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2