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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200630
Report Date: 03/23/2022
Date Signed: 03/23/2022 06:42:33 PM

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
02/03/2022 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20220203090404
FACILITY NAME:BYRON PARKFACILITY NUMBER:
079200630
ADMINISTRATOR:JENNIFER MURRAY PASTORAFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:151CENSUS: 78DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ernesto Navas, Maintenance director and Gia Aron, resident care director TIME COMPLETED:
07:00 PM
ALLEGATION(S):
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9
Resident care plan was not adhered to.
INVESTIGATION FINDINGS:
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8
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11
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13
On3/23/2022, Licensing Program Analysts (LPAs) J. Sampair and L. Ibo arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Ernesto Navas and explained the purpose of the visit. Administrator is not available during the visit.
During the complaint investigation, LPAs reviewed documents and conducted interviews. Based on records review, the care plan indicated that R1 and R2 needed escorting assistance to the dining room and activities two times a day. However, based upon review of the records and interviews, the facility has not been providing escort assistance to R1 and R2, because they stay in their room for all of their meals and they do not participate in any activities.
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. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.
Exit interview with Resident Care Director Gia Aron & assisted living director Jessica Wallace conducted and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 4
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
02/03/2022 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20220203090404

FACILITY NAME:BYRON PARKFACILITY NUMBER:
079200630
ADMINISTRATOR:JENNIFER MURRAY PASTORAFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:151CENSUS: 78DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ernesto Navas, Maintenance director and Gia Aron, resident care director TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not adhere to the regulation on increasing level of care.
INVESTIGATION FINDINGS:
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9
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13
On 3/23/2022, Licensing Program Analysts (LPAs) J. Sampair and L. Ibo arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Ernesto Navas and explained the purpose of the visit.

During the course of the investigation, LPA J. Sampair reviewed documents. LPAs also interviewed staff, residents, and resident representatives concerning facility pricing increases in the assisted living level of care fees.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview with Resident Care Director Gia Aron and assisted living dictore Jessica Wallace conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 4
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
02/03/2022 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20220203090404

FACILITY NAME:BYRON PARKFACILITY NUMBER:
079200630
ADMINISTRATOR:JENNIFER MURRAY PASTORAFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:151CENSUS: 78DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ernesto Navas, Maintenance director and Gia Aron, resident care director TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not adhere to 60 day notice for change in rent.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On3/23/2022, Licensing Program Analysts (LPAs) J. Sampair and L. Ibo arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Ernesto Navas and explained the purpose of the visit. Administrator is not available during the visit.

Facility provided sufficient notice for increase of basic service rate or rent. Notice was provided to residents and family on November 1, 2021 with effective date of January 1, 2022.

Based on information gathered, the allegation is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview with Resident Care Director Gia Aron and Assisted living director Jessica Wallace conducted and a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220203090404
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: BYRON PARK
FACILITY NUMBER: 079200630
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/01/2022
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
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Resident care director Gia Aron and Assisted Living Director Jessica Wallace agreed to schedule a meeting with R1 & R2's representative to update R1 & R2's care plan and fax a copy to CCL by POC date.
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Based on records review and interviews, facility failed to follow R1's & R2’s Care Plan. Care Plan indicates that R1 & R2 receive escort assistance to dining room two times a day. However, staff confirmed R1 & R2 were not receiving escort assistance to the dining room two times a day.
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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: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4