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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200774
Report Date: 02/23/2023
Date Signed: 02/23/2023 10:30:55 AM

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
06/28/2022 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20220628103007
FACILITY NAME:HODGES CARE HOME #3FACILITY NUMBER:
079200774
ADMINISTRATOR:HODGES-WATSON, MYAFACILITY TYPE:
735
ADDRESS:2986 GILMATELEPHONE:
(510) 283-5309
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 4DATE:
02/23/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amika Knighten, CaregiverTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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No staff on duty at the facility.
INVESTIGATION FINDINGS:
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On 02/23/2023 at 09:30am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings for the above allegation. LPA met with Amika Knighten, Caregiver and explained the purpose of the visit. LPA spoke with Administrator over the phone and she approved caregiver to sign forms.

Allegation: No staff on duty at the facility.

During the course of investigation, the department interviewed 2 staff (S1 & S2), Reporting Party (RP) and 1 client (C1); and obtained & reviewed documents: staff roster, Physician's Report, LIC601, Admission Agreement.

RP stated that C1 returned to the facility early on 6/24/2022 from work because C1 felt ill, RP asked to speak to S1, C1 then informed RP that it’s S1 day off and there were no staff for RP to speak to because

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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-20220628103007
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: HODGES CARE HOME #3
FACILITY NUMBER: 079200774
VISIT DATE: 02/23/2023
NARRATIVE
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Continue from LIC9099

there was no staff on duty. RP stated that C1 told RP that he called S1 and she told C1 to wait in the backyard and staff will be at the facility shortly. S2 arrived at the facility and spoke with RP about C1

S1 stated that the facility received a phone call from the day program requesting the facility pick up 2 clients because they had tested positive for COVID-19. S1 stated C1 was gone and not expected to be back to the facility until 3:00pm. C1 called S1 while S2 went to the day program to pick up the 2 clients. S1 stated that she directed C1 to sit in the backyard and S2 will be back to the facility. S1 stated that S2 explained the situation to RP upon her return to the facility.

S2 stated that S2 kind of remember the day and S2 knows she received a phone call from the day program requesting S2 to come and pick up 2 clients (C2, C3) that tested positive for COVID-19.

C1 stated that sometimes C1 has a good memory. C1 stated he came home early and no one was at the facility and when this happens, he will take a walk until they get back to the facility. C1 stated that S1 told him to wait in the backyard. C1 stated that he didn’t wait long maybe an hour (C1 stated he thinks but C1 is not sure) for staff to return to the facility. C1 stated that this didn’t happen often, staff returned to the facility and spoke with RP.

LPA verified the facility reported 3 clients were tested positive on 6/24/2022 by Matt Henson Supervisor at Visitability Day Program. LPA viewed C1s records, C1 has the capacity for self-care and able to leave the facility unassisted.

Based upon records review, interviews conducted, and observations made, the Department has investigated the above allegations and found that they are Unsubstantiated. A finding that the complaint allegation/s are Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.



Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2