<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200778
Report Date: 04/07/2022
Date Signed: 04/07/2022 04:55:55 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
04/01/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220401100741
FACILITY NAME:SOPHIA'S HOMEFACILITY NUMBER:
079200778
ADMINISTRATOR:HAYAG, LORNAFACILITY TYPE:
735
ADDRESS:5243 CONCORD BLVDTELEPHONE:
(925) 683-1818
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ernesto Golez/Licensee and
Lorna Hayag/Administrator		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident (R1) is being unlawfully evicted.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff Reyanto Dingalan. LPA spoke with Ernesto "Butch" Golez, licensee, over the phone and informed the purpose of visit. Licensee arrived after 45 minutes followed by Lorna Hayag, administrator.

LPA reviewed resident (R1) records including but not limited to LIC602 Physician's Report and 30-day eviction and conducted interviews. LPA obtained copies of LIC602, Admission Agreement, Individual Service Plan (ISP), 30-day Review dated 1/20/2020, Quarterly Review and Addendum to ISP

The 30-day eviction indicated the following reasons:
1. Facility can no longer effectively meet R1's needs, especially R1's medical needs.
During interview, licensee and administrator stated that the increase in medical needs that the facility can not provide are taking R1 to the dentist andtaking to appointments with physical therapist and doctor.
....continued next page
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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 3
Control Number 15-AS-20220401100741
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: SOPHIA'S HOME
FACILITY NUMBER: 079200778
VISIT DATE: 04/07/2022
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
 Review of records confirmed the licensee and administrator's statements; however, Admission Agreement indicated that facility is to provide assistance with obtaining a doctor and medical services as needed. Administrator and staff (S1) confirmed that R1 does not need assistance with activities of daily living (ADLs) such as bathing, feeding, dressing, toileting and feeding consistent with R1's LIC602 Physician's Report.
2. R1 has been exhibiting challenging behaviors manifested by mis-communication, mis-perception, over-reaction and/or magnification of an incident
This reason for eviction does constitute ground for eviction.
Administrator stated that R1's family member has been informing her that they (staff) need to repeat and ask R1 number of times due to R1 may seem to understand but may actually not. R1's Quarterly Review dated February 9, 2021 listed behavior of yelling with frustration indicated as antecedent condition when R1 is not able to communicate well. LPA interviewed the administrator and S1 who both indicated R1 does not have aggressive nor self-injurious behavior. Administrator indicated R1 only had yelling episode twice when R1 moved-in consistent with Quarterly Review. Facility does not have documentation nor have Behavior Tracking Log to support R1 is exhibiting behaviors.

Based on information obtained, the preponderance of evidence is met, therefore the allegation is substantiated. The facility issued 30-day eviction for R1 with reasons that do not constitute grounds for eviction.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with licensee and administrator,

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220401100741
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: SOPHIA'S HOME
FACILITY NUMBER: 079200778
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited
CCR
85068.5(a)(1)(2)..
1
2
3
4
5
6
7
85068.5 Eviction Procedures
(a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit for any of the following reasons:(1) Nonpayment of the rate for basic services within ten days of the due date. (2) Failure of the client to comply with state or local law......(3)(4)(5)........
1
2
3
4
5
6
7
Licensee and/or administrator to do the following and submit proof by 4/21/2022.
1. Withdraw the eviction
2 Read the Regulation and submit self-certification.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

-Based on interview and records review, the licensee did not comply with the section above when 30-day eviction was issued for R1 which posed a potential personal rights risk to person in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3