079200392-3-21-2024-15-AS-KHOS-D3XHUL-20240402063030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200392
Report Date: 03/21/2024
Date Signed: 03/21/2024 01:54:03 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
12/19/2023 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231219162259

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: 6	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Merla Fernandez, Caregiver		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff member financially abuses resident

Staff falsified resident’s documents

Staff don't answer facility phone

INVESTIGATION FINDINGS:

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On 3/21/2024 at 12:40pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Merla Fernandez, Caregiver and explained the reason for the visit. LPA spoke with Administrator, Edwin Liwanag, via telephone. LPA obtained approval for Caregiver to sign documents.

During the course of the investigation LPA interview staff, Reporting Party (RP), Resident 1 (R1), obtained and reviewed records.

Allegation: Staff member financially abuses resident.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

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-20231219162259

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: 03/21/2024

NARRATIVE

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Continued from LIC9099.

During interview with RP it was stated that R1's rent was increased without knowledge and S1 has access to R1's bank accounts. Based on record review of the physician's report dated November 10, 2022, R1 is able to manage his own cash resources. Interviews with S1 and R1 indicates that R1 handles his own money and pays his own rent. S1 stated that R1's rent has been the same since he was admitted and that he has no access to R1's accounts. LPA reviewed cancelled checks written by R1 for his rent. Based on the investigation the above allegations are unsubstantiated.

Allegation: Staff falsified resident’s documents.

During interview with RP it was stated that S1 falsified documents for R1. Based on interview with S1 he drove R1 to the bank, but R1 went in and took care of his business. S1 also stated he helped R1 find a tax preparer because R1 asked for help. S1 did not sign any documents at the bank or tax preparer. R1 stated he has all his documents. LPA observed bank statements kept by R1.

Allegation: Staff don't answer facility phone

During interview with RP it was stated that the facility staff would not allow her to speak with R1. During investigation LPA observed while at the facility staff answering telephone. Staff stated they do answer the facility line, but if a resident does not want to talk they respect their personal rights.

Based upon the interviews and information obtained during investigation. The above allegations are 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.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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