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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200296
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:44:29 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
05/26/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210526105438
FACILITY NAME:ALAMO RESIDENCE HOME, INC.FACILITY NUMBER:
079200296
ADMINISTRATOR:NANCY CHIHWAN OHFACILITY TYPE:
740
ADDRESS:2978 MIRANDA AVENUETELEPHONE:
(925) 837-0521
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 6DATE:
02/18/2022
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Nancy Oh, LicenseeTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Resident didn’t receive medication as prescribed
INVESTIGATION FINDINGS:
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On 2/17/2022 at 1:10 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to deliver findings for the above allegations. LPAs met with Administrator, Joy Manalang and explained the purpose of the visit. Licensee, Nancy Oh later arrived at 2:13 PM.

During the course of the investigation, LPA L. Francisco obtained information, collected documents, interviewed 3 staff and witness. It was alleged by reporting party that resident didn’t receive medication as prescribed. Based on record review, LPA observed resident (R1) has a doctor’s order for morphine and it is to be administered every 6 hours around the clock or every 2 hours for breakthrough pain. However, LPA discovered during an interview with staff (S1) that morphine was not administered to R1 in the evening. S1 stated staff did not want to disturb R1 from R1's sleep because R1 did not appeared to be in pain. W1 from hospice agency observed R1 was screaming in pain in the morning when W1 arrived at facility.

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
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
Control Number 15-AS-20210526105438
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: ALAMO RESIDENCE HOME, INC.
FACILITY NUMBER: 079200296
VISIT DATE: 02/18/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
05/26/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20210526105438

FACILITY NAME:ALAMO RESIDENCE HOME, INC.FACILITY NUMBER:
079200296
ADMINISTRATOR:NANCY CHIHWAN OHFACILITY TYPE:
740
ADDRESS:2978 MIRANDA AVENUETELEPHONE:
(925) 837-0521
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 6DATE:
02/18/2022
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Nancy Oh, LicenseeTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Facility failed to maintain medication log
INVESTIGATION FINDINGS:
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On 2/17/2022 at 1:10 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to deliver findings for the above allegations. LPAs met with Administrator, Joy Manalang and explained the purpose of the visit. Licensee, Nancy Oh later arrived at 2:13 PM.

During the course of the investigation, LPA L. Francisco obtained information, collected documents, interviewed 3 staff and witness. It was alleged facility failed to maintain medication log. However, 3 of 3 staff stated administration of morphine was being documented on a notebook. 1 of 3 staff stated notebook was given to R1's responsible party on May 11, 2021. LPA reviewed a sample of 3 resident's medication log and LPA observed records to be complete.

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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210526105438
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: ALAMO RESIDENCE HOME, INC.
FACILITY NUMBER: 079200296
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2022
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care
(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Admiistrator agrees to review regulation and provide in-service training with staff and submit a copy of training agenda with staff signatures to CCL by POC date.
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Based on interview and record review, Licensee did not comply with the regulation cited above. R1 was not administered rountine and PRN morphine as ordered by the doctor which poses an immediate health and 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4