079200772-9-1-2023-15-AS-KHOS-CVSL79-20230918082959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200772
Report Date: 09/01/2023
Date Signed: 09/01/2023 07:02:15 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
09/09/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210909163433

FACILITY NAME:	REVITALIZE CARE HOME LLC		FACILITY NUMBER:	079200772
ADMINISTRATOR:	DACE, GENEVIEVE		FACILITY TYPE:	735
ADDRESS:	1913 CARDIFF DR		TELEPHONE:	(925) 705-8635
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 5	DATE:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Rachelle Wormely/House Manager		TIME COMPLETED:	07:05 PM

ALLEGATION(S):

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-Staff does not prevent a client from harm while in care.
-Staff did not address a client's medical needs while in care.
-Client was unlawfully evicted while in care
-Client is being fed unhealthy food while in care
-Client is being mistreated while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Rachelle Wormely. house manager, and informed the purpose of visit. LPA spoke over the phone with Rhonda Simpson, administrator, and discussed the allegations. LPA also met with other staff, Sharon Gibson.

During the course of investigation, LPA obtained copies of staff schedule, visitor's log, weekly menus and restraining order. LPA also obtained copies of the following client's documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; Individual Program Plan; Individual Service Plan; records of medical appointments; medical records; hospital discharge document; Semi-annual/Quarterly Behavior Progress Reports; Special Incident Reports. LPA inspected the food supplies and conducted interviews on 9/16/21, 7/05/22 and 10/12/22., and 9/01/23
.
......continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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-20210909163433

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: 09/01/2023

NARRATIVE

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Allegation: Staff does not prevent a client (C1) from harm while in care.
It was alleged that the facility allowed C1 to be out for extended the hours and when C1 returned, C1 had bruises and cuts. Reporting party further stated that C1 engages in self harm, often when C1 was with BF.

Review of records showed C1 can leave the facility unassisted and has history of self-harm. Four staff interviewed denied hurting C1. One of these staff stated C1 has history of self-harm but she has never observed C1 physically harming herself when C1 was at the facility and that C1 maybe self-harming when out in the community with BF. Two of the clients interviewed stated the staff are treating them good. Regional Center of East Bay (RCEB) Case Manager (CM2) confirmed C1 has history of cutting herself but the incidents happened when C1 was out in the community.

Allegation: Staff did not address a client's medical needs while in care.
Reporting party (RP1) stated RP1 supports C1's medical and mental health appointments and the facility was not been supportive with these, and C1 missed injection a couple of times. Reporting pary (RP2) reported that client (C4) has been complaining of a severe toothache when C4 moved-in and RCEB's Interdisciplinary Team has been working with the facility providing resources and even has offered to pay for any services given the client’s circumstance.

Review of C1's records showed C1 had injections and doctor's visits. S1 stated C1 missed appointments when C1 was out with BF but she made sure C1 has caught up with the vaccinations and dental appointments except for the front teeth. C1 didn't want to do to dental appointment for front teeth because C! didn't want to be put to sleep. C1 stated missing the appointments when C1 is out in the community.

Information was obtained from RCEB who stated that due to C4 lacking personal documents, providers won't provide service. RCEB was able to obtain the documents from C4's parents and service was eventually provided. C4 was interviewed who confirmed C4 was seen by a dentist and C4's teeth no longer hurt.

....continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20210909163433

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: 09/01/2023

NARRATIVE

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Allegation: C1 was unlawfully evicted while in care.
RP1 alleged that C1 was with RP1 due C! had to complete an interview and had to go through physical examination. When RP1 tried to bring C1 back to the facility, staff told them that C1 was evicted.

LPA reviewed records and found no record of eviction. S1 stated that there was no eviction issued for C1. S1 further stated she does not remember how it started but because there's a restraining order against C1's boyfriend (BF), and C1 is not conserved and can leave the facility unassisted, the move out was processed. and the whole care team (RCEB and facility staff) worked on it and that C1 was on board on the move-out.

Allegation: Client is being fed unhealthy food while in care
RP1 alleged that when C1 moved-in, C1 gained a lot of weight. RP1 further alleged that clients are fed a lot of junk food and a lot of pizza.

LPA conducted inspection and observed food supplies of different varieties. LPA didn't observe pizza in the refrigerator and freezer. LPA interviewed staff (S1 and S2) who stated they serve pizza but not all the time. S1 indicated that C1 has injections with weight gain as side effect. LPA interviewed 3 clients including C1 who all stated they were served meals of different varieties. They were served pizza but not all the time.

Allegation: Client is being mistreated while in care.
Two clients indicated they were treated good by the staff. Three staff interviewed denied yelling and/or mistreating clients. C1 stated she does not remember if any of the staff yelled at her.

Based on all information gathered, the 5 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there are not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited, Exit interview conducted and copy of this report provided to Rachelle Wormely

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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