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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200603
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:36:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/27/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20241227101123
FACILITY NAME:OUR HOMEFACILITY NUMBER:
079200603
ADMINISTRATOR:DUGAN, BERNADETTEFACILITY TYPE:
735
ADDRESS:370 VERNAL DRIVETELEPHONE:
(925) 933-8706
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 2DATE:
01/22/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bernadette Dugan, LicenseeTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff is mismanaging residents medications
Staff is not providing adequate food service to residents
Staff is not providing adequate cleaning supplies for residents
Resident is not accorded privacy
INVESTIGATION FINDINGS:
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On 1/22/2025 at 10:00 AM, Licensing Program Analysts (LPAs) A Gomez and J Clancy-Czuleger arrived unannounced to deliver findings of the complaint investigation in regard to the allegations above. LPAs met with Administrator, Bernadette Dugan and explained the purpose of the visit.

On 12/31/2024 LPA's and AGPA reviewed records, interviewed clients, administrator, and toured facility. On 1/16/2025 LPA interviewed W1 over the phone.

Report Continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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 7
Control Number 15-AS-20241227101123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200603
VISIT DATE: 01/22/2025
NARRATIVE
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On the allegation “Staff is mismanaging residents medications.” it was found during file review on 12/31/2024 that C2’s medications are not being administered correctly. It was observed that there were several days that medication had been missed and there was no documentation available to explain the missed medication. Licensee insisted that the client was given their medication however a count of the medication showed that there were doses that had been skipped. On the allegation “Staff is not providing adequate food service to residents” it was found during interviews and observation on 12/31/2024 that the clients in care do not have access to food throughout the day. The refrigerator and freezer is stocked with food that is not microwaveable and the clients only have a microwave available for use throughout the day. Licensee also states that they regularly leave clients home by themselves throughout the day and typically only makes dinner in the evenings. On the allegation “Staff is not providing adequate cleaning supplies for residents.” it was found during interviews and observations on 12/31/2024 that clients do not have access to cleaning supplies of any kind. When administrator was questioned about the lack of supplies they stated that the clients are not allowed to use cleaning supplies unsupervised. When LPA asked what the clients are to do if they spill something the Administrator stated that the clients could call or text them and that they would supervise them with cleaning, however it is noted that the administrator often leaves clients at the facility while they are running errands which would require the clients to wait until the Licensee is back at the facility to receive assistance. On the allegation “Resident is not accorded privacy” it was found during interviews and observation on that the Licensee goes into clients rooms unannounced while they are in their rooms and that the Licensee discusses private matters about clients with other clients. During the visit on 12/31/2024 LPA and AGPA observed the licensee going into C2’s room without knocking or asking to come in.

***A Civil Penalty in the Amount of $250 is being assessed for repeat violation within a 12 month period***

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), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20241227101123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200603
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2025
Section Cited
CCR
80075(b)(5)(B)
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(b)Clients shall be assisted... medications.(5)If the client's ...requirements are met(B)Once ordered...given according to the physician's directions.

This requirement was not met as evidenced by:
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By POC date Licensee agrees to review clients medications and administer them as perscribed and notify CCLD
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Based on record review the Licensee did not comply with the section cited above by not administering medications correctly which poses an immediate safety risk to clients in care.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20241227101123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200603
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2025
Section Cited
CCR
80072(a)(1)
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(a) Except for children’s... each client shall have...(1)To be accorded dignity...persons.

This requirement was not met as evidenced by
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By POC Licensee agrees to review regulations and notify CCLD.
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Based on interviews and observations the Licensee did not comply with the section cited above by entering clients rooms unnanounced and discussing other clients private matters which poses a potential personal rights violation to clients in care.
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Type B
01/23/2025
Section Cited
CCR
80072(a)(2)
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(a) Except for children’s...the following:(2)To be accorded... equipment to meet his/her needs.

This requirement was not met as evidenced by:

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By POC Licensee agrees to make readily available paper towels, trash bags and other non-hazerdous cleaning supplies to clients and notify CCLD.
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Based on interviews and observations the Licensee did not comply with the section cited above by not readily allowing basic equipment for clients to clean up with which poses a potential personal rights violation to clients in care.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20241227101123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200603
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
Section Cited
CCR
80076(a)(1)
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(a) In facilities providing meals...:
(1) All food shall be...in the quantity necessary to meet the needs of the clients...manner.

This requirement was not met as evidenced by:
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Since the visit on 12/31/2024 the Licensee has made available microwaveable foods for clients. POC cleared.
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Based on interviews and observations the Licensee did not comply with the section cited above by only having non-microwavable food available when clients only have access to a microwave which poses a personal rights risk to clients in care.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/27/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20241227101123

FACILITY NAME:OUR HOMEFACILITY NUMBER:
079200603
ADMINISTRATOR:DUGAN, BERNADETTEFACILITY TYPE:
735
ADDRESS:370 VERNAL DRIVETELEPHONE:
(925) 933-8706
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 2DATE:
01/22/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bernadette Dugan, LicenseeTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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Staff is not allowing resident back into the facility
INVESTIGATION FINDINGS:
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On 1/22/2025 at 11:40 PM, Licensing Program Analysts (LPAs) A Gomez and J Clancy-Czuleger arrived unannounced to deliver findings of the complaint investigation in regard to the allegations above. LPAs met with Administrator, Bernadette Dugan and explained the purpose of the visit.

On 12/31/2024 LPA's and AGPA reviewed records, interviewed clients, administrator, and toured facility. On 1/16/2025 LPA interviewed W1 over the phone.

Report Continues on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20241227101123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200603
VISIT DATE: 01/22/2025
NARRATIVE
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On the allegation “Staff is not allowing resident back into the facility” it was found during interviews that while the Licensee did tell C1 that they could not come back to the facility while on a visit they did allow the resident in the facility when they return therefore the allegation is Unsubstantiated.

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 this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7