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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200622
Report Date: 10/26/2022
Date Signed: 10/26/2022 10:09:45 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
07/01/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200701120309
FACILITY NAME:SPRINGTIME RESIDENCE LLCFACILITY NUMBER:
079200622
ADMINISTRATOR:EMILY KONG COFACILITY TYPE:
740
ADDRESS:2752 MOHAWK CIRCLETELEPHONE:
(925) 867-2942
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:0CENSUS: 0DATE:
10/26/2022
ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lawrence Co, LicenseeTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff did not notify resident's authorized representative of a change in condition.
INVESTIGATION FINDINGS:
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On 10/26/2022 at 9:00AM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegation. LPA spoke with Licensee, Lawrence Co.

During the course of investigation, LPA interviewed staff, witnesses, and complainant. LPA reviewed and obtained admission agreement, medical assessment, care plan, hospice documents, and hospice clinical notes.

Interview with complainant and witnesses revealed that staff did not notified responsible party or hospice when R1 had a change in condition. Hospice notes indicated that facility did not contact nurse for assistance when R1 had terminal restlessness. Interview with staff revealed that when R1 had a change in condition, responsible party wasn't notified until the following day. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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 5
Control Number 15-AS-20200701120309
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: SPRINGTIME RESIDENCE LLC
FACILITY NUMBER: 079200622
VISIT DATE: 10/26/2022
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20200701120309
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: SPRINGTIME RESIDENCE LLC
FACILITY NUMBER: 079200622
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
CCR
87468.1(a)(8)
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Personal Rights of Residents in All Facilities. To have their representatives regularly informed by the licensee of activities related to care or services... This requirement is not met as evidence by:
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No plan of correction at this time. Facility had a change of ownership and has been closed.
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Based on investigation, licensee did not comply with the section cited above by not notifying responsible party of R1's changes in condition which poses a potential health and safety risk to the persons 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/01/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200701120309

FACILITY NAME:SPRINGTIME RESIDENCE LLCFACILITY NUMBER:
079200622
ADMINISTRATOR:EMILY KONG COFACILITY TYPE:
740
ADDRESS:2752 MOHAWK CIRCLETELEPHONE:
(925) 867-2942
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:0CENSUS: 0DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lawrence Co, LicenseeTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
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9
Staff did not provide services agreed upon in the admission agreement.
Staff did not obtain medical attention for resident in a timely manner.
Resident's needs were not met.
INVESTIGATION FINDINGS:
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On 10/26/2022 at 9:00AM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegations. LPA spoke with Licensee, Lawrence Co.

During the course of investigation, LPA interviewed staff, witnesses, and complainant. LPA reviewed and obtained admission agreement, medical assessment, care plan, hospice documents, and hospice clinical notes.

Staff did not provide services agreed upon in the admission agreement.
Admission agreement did not indicate that a dedicated night staff would be assigned to R1 throughout the night. Interview with staff revealed R1 was checked on at night time, but did not have a dedicated night staff for R1. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20200701120309
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: SPRINGTIME RESIDENCE LLC
FACILITY NUMBER: 079200622
VISIT DATE: 10/26/2022
NARRATIVE
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Staff did not obtain medical attention for resident in a timely manner.
R1 had been on hospice care due to terminal illness. Hospice care plan and goals were to manage R1's pain and to keep R1 comfortable. Interview with staff and witnesses revealed that R1 had terminal restlessness and hospice nurse followed up to adjust R1's medications.

Resident's needs were not met.
Interview with staff revealed that staff provided ADL (Activities of Daily Living) care to R1 and provided pain medications as directed by hospice. Hospice notes indicated that R1's pain was well managed by staff.

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

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5