079200765-11-8-2021-15-AS-KHOS-CJW52V-20221004193457

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200765
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:30:49 PM

Unsubstantiated

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
12/03/2020 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20201203154308

FACILITY NAME:	PLEASANT HILL OASIS		FACILITY NUMBER:	079200765
ADMINISTRATOR:	ELEGADO, LIZA		FACILITY TYPE:	740
ADDRESS:	40 BOYD RD		TELEPHONE:	(925) 937-5348
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	44	CENSUS: 44	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Liza Elegado, Executive Director		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Facility staff lock resident in their room

INVESTIGATION FINDINGS:

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

On 11/8/2021 at 1:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegation above. LPA met with staff, Delia Perez. Executive Director, Liza Elegado arrived an hour later.

During the investigation, LPA interviewed staff. LPA reviewed and obtained R1's file including physician's report, care plan, care notes, and resident's checklist in & out of facility. Interview with staff revealed that a latch was placed outside R1's door. However, R1's room has a sliding glass door which allowed R1 to the leave the room into the backyard of the facility. LPA observed R1's sliding glass door does not lock from the outside.

(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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 2

Control Number 15-AS-20201203154308

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: PLEASANT HILL OASIS	FACILITY NUMBER: 079200765
	VISIT DATE: 11/08/2021

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

R1 was non-compliance with the State's shelter-in-place order and would leave the facility regularly at various hours of the day indicated in the resident's checklist in & out of facility. S1 needed to protect other residents from COVID-19 during the pandemic. R1 was never locked in the room as the sliding glass door was a second exit for R1.

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

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2