079200302-6-26-2023-15-AS-KHOS-CTDH5M-20230703055345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200302
Report Date: 05/12/2023
Date Signed: 06/26/2023 11:26:13 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
04/19/2023 and conducted by Evaluator Carol Fowler

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230419164121

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: 4	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	PAMELA GREEN, ADMINISTRATOR		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff denied resident visitors

INVESTIGATION FINDINGS:

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On 5/12/2023 at 12:05 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with by Administrator, Pamela Green and explained the reason for the visit.

During the complaint investigation, LPA interviewed RP and 1 staff. LPA reviewed and obtained the following documents for R1: (physician reports, admission agreement, identification and emergency information, and Power of Attorney (POA), hospice care plan, after visit summary, hospice plan of care order, conservatorship court document, letter from Sutter Health and progress notes.

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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20230419164121

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: 05/12/2023

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Continue from LIC9099

ALLEGATION: Staff denied resident visitors

Investigation finding: UNSUBSTANTIATED

Interview with RP revealed S1 denied a visit with R1. When RP arrived at the facility RP was informed by S1 that R1 had a visit for the day and would not be able to have another visitor for the day.

Interview with S1 revealed that R1 has a note from R1’s doctor stating it is recommended that R1 visits are limited to one person per day for no more than 30 minutes

Interview with W1 revealed that W1 agrees with the recommendations of the doctor and wishes to limit visitation one person per day no longer than 30 minutes.

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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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