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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200734
Report Date: 03/30/2023
Date Signed: 04/12/2023 11:58:53 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
11/10/2021 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211110151724
FACILITY NAME:BAY CARE ASSISTED LIVING LLCFACILITY NUMBER:
079200734
ADMINISTRATOR:ONYEAGOCHA, ROSE CFACILITY TYPE:
740
ADDRESS:2352 SHANNON AVETELEPHONE:
(510) 964-1669
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 3DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rose Onyeagocha, Administrator
Gloria Amaya, Care Staff		TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility failed to properly assess resident prior to rate increase
INVESTIGATION FINDINGS:
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On 04/12/23 at 11:45 AM, Licensing Program Analyst (LPA) L. Holmes amended allegation and met with Gloria Amaya, Care Staff. On 03/30/23 at 12:00 PM, Licensing Program Analyst LPA arrived unannounced to deliver findings for the above allegation. LPA met with Administrator (ADM), Rose Onyeagocha and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, collected documents, reviewed records, interviewed staff and resident. It was alleged facility failed to reassess resident prior to rate increase. Based on record review, LPA observed an email notifying R1’s responsible party of a rate increase in care. LPA L. Francisco observed the last appraisal was completed on April 24, 2020 and not signed by R1’s authorized representative.
Based on LPAs observations and interviews which were conducted and record reviews, the
preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal rights and a copy of this report provided to ADM.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
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
Control Number 15-AS-20211110151724
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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2023
Section Cited
CCR
87463(c)
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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative…when there is significant change...in condition...every 12 months, whichever occurs first…
This requirement is not met as evidenced by:
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By POC date, Administrator agrees to review regulation and submit self-certification letter of understanding to CCLD.
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Based on record review, Licensee did not comply with the regulation cited above by not updating R1’s appraisal within a 12 month period. LPA observed R1’s Needs and Services Plan was last updated on 4/24/2020 and without signature which poses a potential health and safety risk to 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
11/10/2021 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211110151724

FACILITY NAME:BAY CARE ASSISTED LIVING LLCFACILITY NUMBER:
079200734
ADMINISTRATOR:ONYEAGOCHA, ROSE CFACILITY TYPE:
740
ADDRESS:2352 SHANNON AVETELEPHONE:
(510) 964-1669
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 3DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rose Onyeagocha, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff will not call authorized representative back
INVESTIGATION FINDINGS:
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On 04/12/23 at 11:45 AM, Licensing Program Analyst (LPA) L. Holmes amended allegation with Gloria Amaya, Care Staff. On 03/30/23 at 12:00 PM, LPA arrived unannounced to deliver findings for the above allegation. LPA met with Administrator, Rose Onyeagocha and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, collected documents, reviewed records, interviewed staff and resident. It was alleged staff will not call authorized representative back. However, based on LPA L. Francisco’s interview with S1 on 11/19/2021, facility return calls immediately and staff will inform S1 if S1 needs to be reached.

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 to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
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
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
11/10/2021 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211110151724

FACILITY NAME:BAY CARE ASSISTED LIVING LLCFACILITY NUMBER:
079200734
ADMINISTRATOR:ONYEAGOCHA, ROSE CFACILITY TYPE:
740
ADDRESS:2352 SHANNON AVETELEPHONE:
(510) 964-1669
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 3DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rose Onyeagocha, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
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3
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5
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8
9
Staff is interfering in resident moving out of the facility
INVESTIGATION FINDINGS:
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On 04/12/23 at 11:45 AM, Licensing Program Analyst (LPA) L. Holmes amended allegation with Gloria Amaya, Care Staff. On 03/30/23 at 12:00 PM, LPA arrived unannounced to deliver findings for the above allegation. LPA met with Administrator, Rose Onyeagocha and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, collected documents, reviewed records, interviewed staff and resident. It was alleged staff is interfering in resident moving out of the facility. However, based on interview with S1, the day R1 was supposed to be transferred to the new facility, R1 refused. Interview with R1 confirmed that R1 did not want to move out of the facility.

This agency has investigated the complaint alleging staff is interfering in resident moving out of the facility. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Exit interview conducted and a copy of this report provided to Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
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