079200734-10-13-2023-15-AS-KHOS-CWPLSZ-20231017090134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200734
Report Date: 10/13/2023
Date Signed: 10/13/2023 02:06:08 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
09/28/2023 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20230928111639

FACILITY NAME:	BAY CARE ASSISTED LIVING LLC		FACILITY NUMBER:	079200734
ADMINISTRATOR:	ONYEAGOCHA, ROSE C		FACILITY TYPE:	740
ADDRESS:	2352 SHANNON AVE		TELEPHONE:	(510) 964-1669
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	6	CENSUS: 4	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rose Onyeagocha, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not adequately trained.

Staff are not adequately maintaining residents' records.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/13/2023 at 1:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rose Onyeagocha, Administrator, and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, Reporting Party (RP), and reviewed records.

On the allegation staff are not adequately trained.

RP reported none of the staff have had the required training in direct care or first aid training when working with residents. Two staff were present during the visit and neither one was able to provide LPA with the staff or resident files. During interviews

Continued on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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-20230928111639

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
	VISIT DATE: 10/13/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099.

with staff S1 stated she has first aid training and had trained the new staff but did not record the training. During record review LPA did not observe any training records and that only one staff S3 had first aid training.

On the allegation Staff are not adequately maintaining residents’ records.

RP reported that the residents’ records are not current, which poses a potential problem if the staff is not aware of the residents’ conditions. LPA reviewed all the resident records and observed none of the residents have a current appraisal needs and services plan, two of four were missing the consent form, a current physician’s report, and the ID and emergency information. None of the resident records contained personal rights or safeguards for property/valuables.

Based on LPAs observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Both substantiated allegations were cited on the required annual inspection on 10/04/2023.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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
09/28/2023 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230928111639

FACILITY NAME:	BAY CARE ASSISTED LIVING LLC		FACILITY NUMBER:	079200734
ADMINISTRATOR:	ONYEAGOCHA, ROSE C		FACILITY TYPE:	740
ADDRESS:	2352 SHANNON AVE		TELEPHONE:	(510) 964-1669
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	6	CENSUS: 4	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rose Onyeagocha, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure that residents' diapering needs are met while in care.

Facility is dirty.

Facility is odiferous.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/13/2023 at 1:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rose Onyeagocha, Administrator, and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, Reporting Party (RP), and reviewed records.

On the allegation staff do not ensure that residents’ diapering needs are met while in care. RP reported residents are left in soiled diapers for an extended period of time. Upon LPAs arrival the caregiver was assisting a resident with toileting and changing another resident. During the visit a resident called out for the caregiver to assist her to the bathroom and stated to the LPA that the caregiver always helps her. The caregiver

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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

Control Number 15-AS-20230928111639

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
	VISIT DATE: 10/13/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099.

also changed residents while LPA was visiting. The caregiver stated she checks the resident every hour or so or changes them when at the resident’s request. S1 stated that residents should be checked at least every two hours.

On the allegation facility is odiferous.

RP reported the facility smells bad. Upon arrival LPA did not smell any foul odors on the outside or inside of the facility. LPA did not observe any garbage or dirty laundry that may cause an odor.

On the allegation the facility is dirty.

RP reported the bathroom, floors, and kitchen are filthy. LPA conducted an annual inspection on the same day as opening this complaint. LPA observed the facility being clean and sanitary. LPA did observe some items were blocking the passageways in the back yard. LPA cited the facility under the annual inspection for the items.

Based upon the information obtained and the observation during the investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4