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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200308
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:10:45 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
09/23/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240923102456
FACILITY NAME:SHIRLEY'S CARE HOMEFACILITY NUMBER:
079200308
ADMINISTRATOR:JONES, SHIRLEYFACILITY TYPE:
735
ADDRESS:203 JOAQUIN DRIVETELEPHONE:
(925) 806-0515
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 5DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Shirley JonesTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are mismanaging resident medication
Staff are not adequately trained
INVESTIGATION FINDINGS:
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On 9/27/2024 at 8:00AM Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an initial 10-day complaint visit and deliver findings. LPA met with staff Debra Bates and explained the purpose of the visit. Staff contacted Administrator Shirley Jones and the administrator arrived at approximately 8:40AM.

When LPA arrived at the facility all clients were present and waiting to go to the day program. The only staff on duty at the time of the visit was Debra Bates. On the allegation of staff are mismanaging resident medications LPA observed the facility MAR and saw that the MAR was not complete and inaccurately filled out. LPA also counted pills for C2 and observed that the counts were off and that the medications had not been distributed correctly and did not match the MAR. Based on observation, interview, and record review the allegation of "Staff are mismanaging resident medication" is SUBSTANTIATED.

Report Continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 3
Control Number 15-AS-20240923102456
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: SHIRLEY'S CARE HOME
FACILITY NUMBER: 079200308
VISIT DATE: 09/27/2024
NARRATIVE
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When LPA requested training documentation from the Administrator the Administrator stated that they did not have any documentation. Through interviews LPA also found that staff have not had any of the other required training's this year yet and the medication training they have had occurred last week. Based on observations, record review, and interviews the allegation of "Staff are not adequately trained" is SUBSTANTIATED.

Administrator left the visit early and approved staff Debra to sign the report.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240923102456
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: SHIRLEY'S CARE HOME
FACILITY NUMBER: 079200308
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
80065(f)
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All personnel shall be given on-the-job training ... and as evidenced by safe and effective job performance.

This requirement is not met as evidence by:
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By POC Administrator agrees to train all staff and document the trainings. Administrator agrees to notify CCLD when all trainings are complete.
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Based on observation, interview, and record review staff has not adequately been trained which poses an immediate health and safety risk to clients in care.
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Type A
09/30/2024
Section Cited
CCR
80075(k)
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(k) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidence by:
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By POC Administrator agrees to review all clients medications and develop a system to ensure that medications are distributed accurately. Administrator also agrees to accuratly update MAR and provide trainings and notify CCLD.
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Based on observation, interview, and record review staff are not administering the correct dossage of medications as well as they are not accurately filling out the MAR which poses an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3