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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200772
Report Date: 10/10/2024
Date Signed: 10/10/2024 06:21:03 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
05/01/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240501163714
FACILITY NAME:REVITALIZE CARE HOME LLCFACILITY NUMBER:
079200772
ADMINISTRATOR:DACE, GENEVIEVEFACILITY TYPE:
735
ADDRESS:1913 CARDIFF DRTELEPHONE:
(925) 267-9822
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Clayton Bolds, Direct Support ProfessionalTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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5
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7
8
9
Residents do not have access to food while in care.
INVESTIGATION FINDINGS:
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3
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5
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9
10
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13
On 10/10/2024 at 4:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Clayton Bolds, Direct Support Professional and explained the purpose of the visit. Administrator, Genevieve Dace, arrived at 5:00pm.

During the investigation the LPA interviewed staff, clients, reviewed four (4) staff records, toured kitchen, garage, staff schedule, and obtained food menu.

Allegation: Residents do not have access to food while in care.

During the investigation, LPA toured kitchen, pantry cabinet, and freezer in garage.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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 5
Control Number 15-AS-20240501163714
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: 10/10/2024
NARRATIVE
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Continued from LIC9099.

LPA observed that the facility did not have a 7-day supply of non-perishables and 2-day perishables and the pantry cabinet was locked. While LPA was present LPA observed clients eating lunch. S1 stated during interview that staff was taking the food and Administrator decided not to put a lot of food at the facility.

The allegation is Substantiated and was cited under annual inspection conducted on 5/4/2024. The POC was cleared on 05/06/2024.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/01/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240501163714

FACILITY NAME:REVITALIZE CARE HOME LLCFACILITY NUMBER:
079200772
ADMINISTRATOR:DACE, GENEVIEVEFACILITY TYPE:
735
ADDRESS:1913 CARDIFF DRTELEPHONE:
(925) 267-9822
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Clayton Bolds, Direct Support ProfessionalTIME COMPLETED:
05:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have adequate staffing to meet the needs of residents in care.
Facility is not maintaining files for staff.
Facility is operating out of ratio.
Meals being served to the residents are not nutritious.
Staff left residents in a soiled diaper for a long period of time.
Staff does not ensure that residents are provided with necessary supplies when attending day program
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/10/2024 at 4:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Clayton Bolds, Direct Support Professional and explained the purpose of the visit. Administrator, Genevieve Dace, arrived at 5:00pm.

During the investigation the LPA interviewed staff, clients, reviewed four (4) staff records, toured kitchen, garage, staff schedule, and obtained food menu.

Allegation: Facility does not have adequate staffing to meet the needs of residents in care.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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 5
Control Number 15-AS-20240501163714
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: 10/10/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
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11
12
13
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Continued from LIC9099.

LPA reviewed the staff schedule for 4/28/2024 to 5/4/2024 and observed there was sufficient staff available for clients. S1 stated there are two (2) staff schedule for day, two (2) for swing, and one (1) for night shift. LPA observed C1, C2, and C3 was well groomed.

Allegation: Facility is operating out of ratio.

Based on observation LPA observed two (2) staff present upon arrival with five (5) clients. The two (2) staff present worked 7am - 3pm. One (1) staff was to arrive and work 3pm - 9pm, one (1) 3pm - 11pm, and one (1) 11pm - 8:15am

Allegation: Staff left residents in a soiled diaper for a long period of time.

Based on interviews with S1, S2, and S3 the only client that is incontinent is C1. Staff stated C1 only wears diapers at night. S2 works different shifts per the schedule and stated that C1 does not always wet the diaper. That sometimes she will ask to go to the bathroom.

Allegation: Staff does not ensure that residents are provided with necessary supplies when attending day program.

S1 stated the clients that attending day program takes a lunch and the one (1) client that is incontinent takes a change of clothing and diapers. S1 stated there is nothing for the clients to take unless that need money for community outings.

Allegation: Facility is not maintaining files for staff.

LPA conducted an annual inspection the same day as conducting a complaint investigation and reviewed seven (7) staff files, and five (5) client files. During record review LPA observed all staff and clients’ files were current and complete.

Continued from LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240501163714
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: 10/10/2024
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 LIC9099C.

Allegation: Meals being served to the residents are not nutritious.

During LPA’s tour of facility LPA observed facility needed to purchase perishables and non-perishables for the facility. LPA observed some frozen meat and vegetables. Review of the menu dated 4/28/2024 to 5/4/2024, indicated a variety of foods to be cooked for the clients. C4 and C5 stated during interview that they like the food and they get to eat different foods.

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

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5