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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200565
Report Date: 03/04/2022
Date Signed: 03/04/2022 09:13:30 AM

Substantiated


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
09/14/2021 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20210914085819
FACILITY NAME:COZY FAMILY CAREFACILITY NUMBER:
079200565
ADMINISTRATOR:JI, RUIFACILITY TYPE:
740
ADDRESS:2135 LUPINE ROADTELEPHONE:
(510) 327-4408
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 6DATE:
03/04/2022
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Rui Ji, AdministratorTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Staff are sleeping in the garage
INVESTIGATION FINDINGS:
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Amended to deliver citation

On 3/4/22 (Licensing Program Analyst) LPA C. Fowler arrived unannounced to deliver findings on the above allegation. LPA met with Rui Ji, Administrator.

During the course of the investigation, LPA A. O’Hollaren toured facility, reviewed records, collected and obtained documents. LPA interviewed three (3) staff and three (3) out of six (6) residents. Based on information obtained from reporting party, staff is sleeping in common area. During interviews all three (3) staff and one (1) of three (3) residents confirmed staff sleeps in the living room on a mattress which is stored in the garage during the day.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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 2
Control Number 15-AS-20210914085819
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: COZY FAMILY CARE
FACILITY NUMBER: 079200565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2022
Section Cited
CCR
87307(a)
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87307 Personal Accommodations and Services(a) Living accommodations and grounds shall be related to the facility's function. This requirement was not met as evidenced by:
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Administrator agreed not to allow staff to use the mattress which is stored in the garage to sleep in the living room common area. By POC date, facility will submit to CCLD a written addendum to their operating plan describing how the common areas will be utilized as intended.
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Based on LPA's observation licensee did not comply with the section cited above by allowing staff to sleep on a mattress (that's stored in the garage) in the living room common area. Which poses a potential health and safety risk to residents.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2