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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200212
Report Date: 10/01/2024
Date Signed: 10/01/2024 11:15:11 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
09/24/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240924093439
FACILITY NAME:RES SUCCESSFACILITY NUMBER:
079200212
ADMINISTRATOR:FABIOLA DELA TORREFACILITY TYPE:
775
ADDRESS:2980 RAILROAD AVENUETELEPHONE:
(925) 473-9552
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:72CENSUS: 20DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Fabiola Dela Torre, Program ManagerTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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9
Staff do not ensure medications are dispensed as prescribed
INVESTIGATION FINDINGS:
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On 10/1/2024 at 09:50am, Licensing Program Analysts (LPAs), L. Hall and D. Doidge arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPAs met with Fabiola Dela Torre, Program Manager, and explained the purpose of the visit.

During investigation LPAs interviewed three (3) staff, reviewed C1, C2, C3, and C4's medications and medication administration record (MAR,) obtained a client and staff roster.

Based on interviews and record review there are only four (4) clients receiving medications from staff and there are only four (4) staff administering the medications. LPAs did not observe any medication errors during review of clients MARs.

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

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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-20240924093439
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: RES SUCCESS
FACILITY NUMBER: 079200212
VISIT DATE: 10/01/2024
NARRATIVE
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Continued from LIC9099.

During interviews with all three (3) staff it was stated there has not been any mismanagement of medication. S3 stated she is the main person that gives medication but there are three (3) backup staff when S3 is not available.

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

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2