079200334-7-8-2021-15-AS-KHOS-C5CHYT-20210728063715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200334
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:55:45 PM

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
10/14/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20201014161515

FACILITY NAME:	AMAZING HOME CARE II		FACILITY NUMBER:	079200334
ADMINISTRATOR:	MARILOU SOLOMON		FACILITY TYPE:	740
ADDRESS:	5017 SAINT GARRETT COURT		TELEPHONE:	(925) 671-7909
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 3	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Adonis Solomon/Licensee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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-Facility administrator is not able to perform her duties.

-Facility administrator certificate is expired.

-Facility staff is locking residents in the facility.

-Facility staff is not keeping the facility free of ants.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegations. LPA met with staff, Loriza Sagum and Ruperto Sagum. LPA requested to call Adonis Solomon, licensee, who arrived after about an hour with Almarie Solomon.

During investigation, LPA conducted inspection and interviewed Adonis Solomon and staff (S1). LPA obtained and reviewed resident (R1) records.

Allegation: Facility administrator is not able to perform her duties.
On October 21, 2020, LPA interviewed staff (S1) and Adonis Solomon who both stated that Marilou Solomon, administrator, only came to the facility twice since August 2019. Marilou Solomon is not able to perform her duties as administrator.

.....continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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-20201014161515

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: AMAZING HOME CARE II	FACILITY NUMBER: 079200334
	VISIT DATE: 07/08/2021

NARRATIVE

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Allegation: Facility administrator certificate is expired.
LPA checked and reviewed the active certificate list and pending application list for administrator certificates on Community Care Licensing’s website and didn’t see Marilou’s Solomon’s name. LPA confirmed with Adonis Solomon that Marilou Solomon was not able to renew her administrator certificate.

Allegation: Facility staff is locking residents in the facility.
During inspection, LPA observed a locking mechanism on top of the entrance door. Review of resident (R1) Physician’s Report revealed R1 has wandering behavior and S1 stated the locking mechanism was installed to prevent R1 from leaving the facility.

Allegation: Facility staff is not keeping the facility free of ants.
Reporting party indicated she personally observed ants in the facility. Both S1 and Adonis Solomon confirmed during interview that facility has ants.

Based on all the information obtained, the allegations are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 California Code of Regulations and Health and Safety Code (see 9099Ds). Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Adonis Solomon and Almarie Solomon.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20201014161515

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: AMAZING HOME CARE II	FACILITY NUMBER: 079200334
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/22/2021 Section Cited CCR 87405(d)	1 2 3 4 5 6 7	87405(d) Administrator - Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to hire a new administrator and submit proof by July 22. 2021.
	8 9 10 11 12 13 14	-Based on interviews, licensee did not comply with the above Regulation as Marilou Solomon is unable to perform her duties as administrator which poses potential health and safety risks to persons in care.	8 9 10 11 12 13 14
Type B 07/22/2021 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405(a) Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to hire a new administrator and submit proof by July 22. 2021.
	8 9 10 11 12 13 14	-Based on interviews, licensee did not comply with the above Regulation as Marilou Solomon’s certificate expired and licensee didn’t hire a new administrator	8 9 10 11 12 13 14

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20201014161515

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: AMAZING HOME CARE II	FACILITY NUMBER: 079200334
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/22/2021 Section Cited HSC 1569.269(a)(5)	1 2 3 4 5 6 7	Enumerated rights; severability: Residents of residential care facilities for the elderly shall have all the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Corrected. Licensee removed the locking mechanism.
	8 9 10 11 12 13 14	-Based on inspection, observation and interviews, licensee did not comply with the above Regulation by installing a locking mechanism on front door which poses potential personal rights risk to person in care.	8 9 10 11 12 13 14
Type B 07/22/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Corrected. Licensee had the staff eradicate the ants and ensured the upkeep of the facility.
	8 9 10 11 12 13 14	-Based on interview, licensee did not comply with the above Regulation. Staff and licensee confirmed the facility has ants which poses potential health and safety risks to persons in care.	8 9 10 11 12 13 14

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

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