079200290-12-12-2023-15-AS-KHOS-CZ5HQE-20240103052349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200290
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:46:35 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/11/2023 and conducted by Evaluator James Sampair

COMPLAINT CONTROL NUMBER: 15-AS-20231211090200

FACILITY NAME:	A PLACE FOR SENIORS, LLC		FACILITY NUMBER:	079200290
ADMINISTRATOR:	DISTEFANO, KAMILLA		FACILITY TYPE:	740
ADDRESS:	257 NORMANDY LANE		TELEPHONE:	(925) 516-6665
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 6	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Caregiver Monique Alcindor		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not ensure that facility had a proper lock on the front door of the facility.

INVESTIGATION FINDINGS:

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On 12/12/2023 at 03:05 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the initial 10-day complaint inspection of the facility pertaining to the allegation above. Upon arrival, LPA stated the purpose of the visit to Caregiver Brianna Sapp and Caregiver Monique Alcindor, then stated it again to Licensee/Administrator Kamilla DiStefano over the phone at approximately 3:15 PM.

The complainant alleged that staff did not ensure that facility had a proper lock on the front door of the facility. Shortly after entering the facility, the LPA confirmed that two locks were on the front door. One was the standard lock, which was safe. The other lock was a "butterfly" type of lock that caregivers commonly use to stop residents from exiting and therefore not safe.

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. One (1) Type-B citation was issued (refer to LIC9099-D for details).

Exit interview conducted and a copy of this report provided for Administrator/Licensee via email.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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-20231211090200

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: A PLACE FOR SENIORS, LLC	FACILITY NUMBER: 079200290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/19/2023 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in all Facilities (a) Residents ... have all of the following personal rights: (6) ... to not be locked into any ... facility ... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Lock removed from door during inspection.
	8 9 10 11 12 13 14	Based on observation, the Licensee had an improper lock on the front door, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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