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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200772
Report Date: 07/31/2025
Date Signed: 07/31/2025 04:22:24 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
10/07/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20221007140840
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: 5DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Genevieve Dace/Licensee and
Rhonda Simpson/Administrator 		TIME COMPLETED:
04:25 PM
ALLEGATION(S):
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-Insufficient staffing.
-Staff shares resident's personal information with others.
-Staff refuse to take resident to appointments.
-Staff do not assist resident with incontinence needs.
-Facility providing inadequate meal services.
INVESTIGATION FINDINGS:
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On this day, 7/31/25, at 1:00 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA rang the doorbell twice and no one is home. LPA called and spoke with Genevieve Dace, licensee, over the phone, and informed of LPA's visit. Licensee and Rhonda Simpson, administrator, arrived after about 40 minutes.

During the course of investigation, LPA obtained copies of staff roster/schedule, LIC500 Personnel Report, and reviewed residents' records and obtained copies of including but not limited to the following residents' documents: LIC601 Identification and Emergency Contact Information; Face Sheet; LIC602 Physician's Report; medical and dental appointment visits/records. LPA inteviewed the following: staff (S4) on 10/12/22; staff (S9, S5), licensee on 10/13/22 and 7/31/25; residents (R1, R3) on 10/13/22; 2 staff on 7/31/25. LPA also obtained information from Regional Center of East Bay Quality Assurance Specialist (RQA) and case manager (CM).
....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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-20221007140840
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: 07/31/2025
NARRATIVE
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Page 2

Allegation: Insufficient staffing.
One out of 4 staff interviewed stated the facility was operating out of ratio. Licensee, current administrator and S9 stated the facility has always sufficient staffing. During the time complaint was received, LPA obtained information from RQA who stated that with the total 6 residents at that time, the facility is required to provide 168 hours of per week for basic staffing and 90 hours per week of additional staff for a total of 258 hours per week, but all these information changed due to the administrator during that time no longer work at the facility. LPA obtained information from the house manager during that period who stated that she covered for the hours of the administrator who quit. Therefore, the allegation is unsubstantiated.

Allegation: Staff shares resident's personal information with others.
The reporting party (RP) stated that resident (R1) reported that the personal information of R1 was exposed by S9 to other residents. S9 denied the allegation. CM stated she talked to former administrator about the allegation who told her that no one talked about resident's information in front of other residents. LPA was not able to obtain information from R1 regarding the allegation. Due to medical diagnosis of other residents, LPA was not able to obtain information. Therefore, the allegation is unsubstantiated.

Allegation: Staff refuse to take resident to appointments.
RP indicated that the house manager (HM) does not like resident, R1, and would not take or allow other staff to take R1 to medical appointments. It was also alleged that resident (R3) has dental issues and R3 was not brought to the dentist.

HM denied the allegation and stated that R1 set up her own medical and dental appointments and goes to the appointments via Uber. This was confirmed by LPA from licensee and current administrator. RQA stated that due to R3 lacking a valid photo ID or birth certificate, no provider would provide services even cash based. RCEB was able to get a birth certificate from R3’s parents and services were rendered. R3 stated she was seen by the dentist on the day LPA conducted a 10-day complaint visit. LPA was not able to obtain information from R1. Therefore, the allegation is unsubstantiated.

.....continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20221007140840
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: 07/31/2025
NARRATIVE
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Page 3

Allegation: Staff do not assist resident with incontinence needs.
It was alleged that one of the night staff refuses to change R2 during his shift and has been going on for sometime. It was further alleged that this staff is a friend with licensee, and the licensee has been saying, she will talk to this staff but nothing has changed. This night staff confirmed with LPA that R2 along with other 2 residents need assistance with changing diaper and that he changes them. However, there were times when R2 was not comfortable with this staff doing the changing and he does not want to force change R2 so he asked other staff to do it. He also asked the pm shift staff to change R2 before they leave the facility for the day. The licensee denied the allegation that she and this night staff are good friends. The licensee and current administrator stated they are trying to bladder trained R2 to prevent skin breakdown. The staff are having R2 go to the toilet before R2 goes to bed and that R2 is checked every 2 hours at night. Due to medical diagnosis, LPA was not able to obtain information from R2. Therefore, the allegation is unsubstantiated.

Allegation: Facility providing inadequate meal services.
One of the staff interviewed stated that the former house manager (HM) does not give the residents food options, rations meals, and rations residents milk and juice and makes residents drink water. This staff also stated that after 7 pm if residents are hungry, HM will not allow them to have something to eat. HM denied the allegation and stated that they don't ration food to residents. HM further stated that residents except R2 can get snacks and have access to the refrigerator. Due to medical diagnosis, R2 cannot get her own food but can express if she is hungry and wants food which staff always provide. During the 10-day complaint visit and upon arrival to the facility, 5 of the 6 residents were at the day program but LPA observed the table was set with snacks and residents ate when they arrived. LPA also observed the staff gave after dinner snacks to one of the residents. Therefore, the allegation is unsubstantiated.

Based on all the information gathered, the 5 allegations are closed as unsubstantiated. A finding that a compliant is unsubstantiated means that although the allegations may have happened or are valid, the preponderance of evidence standard is not met.

No deficiency cited. Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5