079200302-3-19-2024-15-AS-KHOS-D8HJDS-20240826065802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200302
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:11:57 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
03/11/2024 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20240311150745

FACILITY NAME:	STUART HOUSE, THE		FACILITY NUMBER:	079200302
ADMINISTRATOR:	PAMELA GREEN		FACILITY TYPE:	740
ADDRESS:	3067 BELFAST WAY		TELEPHONE:	(510) 262-0206
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94806
CAPACITY:	6	CENSUS: 3	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Pamela Green, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff failed to timely seek medical attention to address resident's change in condition.

Facility staff hit resident with a back-scratcher.

INVESTIGATION FINDINGS:

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On 3/19/2024 at 1:30pm, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to open and deliver complaint findings for the allegations above. LPA met with Pamela Green and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with the reporting party, S1 & S2, LPA obtained and reviewed records.

Allegation: Facility staff failed to timely seek medical attention to address resident's change in condition.
Investigation Finding: un-substantiated

Responsible Party (RP) reported R1 didn't received medical attention in a timely manor. LPA conducted a record review and R1 had a medical assessment on 11/8/2023 before R1 moved into the facility. LPA also reviewed R1 hospice care binder and R1 was placed on hospice care on February 14, 2024 R1 had a hospice nurse visit R1 at the facility 5 days a week. Therefore the this allegation is un-substantiated.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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-20240311150745

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: STUART HOUSE, THE	FACILITY NUMBER: 079200302
	VISIT DATE: 03/19/2024

NARRATIVE

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Continued from LIC 9099

Allegation: Facility staff hit resident with a back scratcher.
Investigation Finding: un-substantiated

Responsible Party (RP) reported R1 told RP that R1 was getting hit on R1 legs with a back scratcher. LPA conducted interviews with S1 and S1 stated that the back scratcher belongs to R1 roommate and was located on the dresser. S1 stated that S1 has never hit or knows of any staff that has hit R1 with the back scratcher. LPA interviewed S2, S2 stated that S2 has never hit R1 with a back scratcher. S2 stated that due to R1 diagnoses that R1 would curse at S2 and request S2 not to touch her. S2 stated that R1 would apologize to S2 at the end of the day. Therefore the this allegation is un-substantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations Facility staff failed to timely seek medical attention to address resident's change in condition and Facility staff hit resident with a back scratcher are unsubstantiated.

No deficiencies observed during visit.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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