079200392-10-29-2024-15-AS-KHOS-DB6KF3-20241119065117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200392
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:10:01 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
10/24/2024 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20241024135303

FACILITY NAME:	EMA BOARD AND CAREHOME		FACILITY NUMBER:	079200392
ADMINISTRATOR:	EDWIN LIWANAG		FACILITY TYPE:	740
ADDRESS:	1131 ALAMO WAY		TELEPHONE:	(925) 458-7098
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	10	CENSUS: 5	DATE:	10/29/2024
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Edwin Liwanag, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff does not ensure resident health care needs are being addressed

INVESTIGATION FINDINGS:

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On 10/29/2024 at 1:05pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct an initial 10-day visit and deliver complaint findings for the allegation above. LPA met with Administrator, Edwin Liwanag and explained the reason for the visit.

LPA interviewed staff and resident. LPA requested the following documents to be submitted to CCLD by 10/30/2024: home health visit frequency, home health admission, copy of after summary visit dated 3/11/2024, copies of home health documentation from 9/11/2024 to present.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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-20241024135303

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: EMA BOARD AND CAREHOME	FACILITY NUMBER: 079200392
	VISIT DATE: 10/29/2024

NARRATIVE

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Continued from LIC9099.

Based on interview with W1 facility is not ensuring R1's health care needs are being addressed because R1's primary doctor is in Fremont. S1 stated during interview that R1 refuses to go into the doctor's office, but has had several phone appointments. R1 was last seen in person by a doctor on 3/11/2024. R1's primary physician ordered home health visitation which is being conducted. R1 stated in interview that he doesn't want to go to the doctor and he is fine.

Based upon the information obtained and the interviews conducted during the investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC9099 (FAS) - (06/04)

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