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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200569
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:56:28 AM



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
10/28/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201028095918
FACILITY NAME:PLEASANT HILL VILLA HOME CAREFACILITY NUMBER:
079200569
ADMINISTRATOR:MAGAT, GLICERIA MFACILITY TYPE:
740
ADDRESS:3021 PUTNAM BLVDTELEPHONE:
(408) 933-8663
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 5DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Gliceria Magat, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Residents sustain falls while in care
INVESTIGATION FINDINGS:
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On 09/17/2021 at 09:45AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct complaint investigation and deliver complaint findings for the above allegation. LPA met with Gliceria Magat, Administrator and explained the reason for the visit.

During the course of the investigation LPA interviewed three (3) staff, reviewed residents files, obtained resident and staff roster. Interview with staff indicated that an alarm is placed on fall risk residents and there is only one (1) fall risk resident at this time. Facility has protocol in place to assist residents if resident fall. LPA observed caregiver assisting resident while walking.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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-20201028095918
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: PLEASANT HILL VILLA HOME CARE
FACILITY NUMBER: 079200569
VISIT DATE: 09/17/2021
NARRATIVE
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Continued from LIC9099.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2