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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200772
Report Date: 04/12/2023
Date Signed: 04/12/2023 04:04:48 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
12/27/2022 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20221227100946
FACILITY NAME:REVITALIZE CARE HOME LLCFACILITY NUMBER:
079200772
ADMINISTRATOR:DACE, GENEVIEVEFACILITY TYPE:
735
ADDRESS:1913 CARDIFF DRTELEPHONE:
(925) 705-8635
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 4DATE:
04/12/2023
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Rachelle Wormely, House ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not assist resident with toileting needs

Staff left resident in soiled clothing for extended period of time
INVESTIGATION FINDINGS:
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On 4/12/2023 at 03:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegations. LPA met with Rachelle Wormely, House Manager and explained the purpose of visit.

During the investigation LPA interviewed Reporting Party, six (6) staff, obtained and reviewed documents. Based on the allegation staff do not assist resident with toileting needs. All staff stated there is not any written protocol to check C1. During interview with S1 it was stated that staff has been bladder training C1 and that C1 hardly wets incontinence product during the day. Staff stated during interviews that C1 is reminded every couple of hours to go to the bathroom during the day, and at night staff will check on C1 to see if she is wet. S4 stated during interview that depending on how C1 sleeps at

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
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 2
Control Number 15-AS-20221227100946
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: REVITALIZE CARE HOME LLC
FACILITY NUMBER: 079200772
VISIT DATE: 04/12/2023
NARRATIVE
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Continued from LIC9099.

at night there can be leakage, but C1 has a chux underneath and if C1 is wet then staff will change C1. Based on interviews the above allegations are Unsubstantiated.

On the allegation staff left resident in soiled clothing for extended period of time. During interviews S5 and S6 stated in the past there was an issue a couple of times, but when addressed it was corrected. Other staff stated there has not been an issue with C1 being left in soiled clothing for an extended period of time, because staff takes C1 to the restroom every couple of hours during the day, and if C1 is wet at night C1 is changed.

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

Exit interview conducted. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2