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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200778
Report Date: 12/16/2022
Date Signed: 12/16/2022 02:00:15 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
03/17/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220317153042
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:
12/16/2022
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Butch Golez, LicenseeTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility is not meeting resident's dental hygiene needs.
INVESTIGATION FINDINGS:
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On 12/16/22 at 10:50 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to deliver findings for the above allegation. Upon arrival, LPAs met with Care staff, Reynato Dingalan and explained the purpose of the visit. Licensee, Butch Golez later arrived at 11:00 AM.

During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents and interviewed clients and staff. It was alleged facility is not meeting resident's dental hygiene needs. Based on record review of C1's health contact record, LPA observed C1 has been going to dental appointments since January of 2020. LPA reviewed health contact record dated February 24, 2022 and LPA observed a follow-up was needed for fillings. However, no documentation showed that facility assisted C1 with the follow-up appointment. It was not until a dental emergency was scheduled by C1's family member and procedures were completed.

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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-20220317153042
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: 12/16/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted with Licensee. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220317153042
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: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited
CCR
80075(a)
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80075(a) HEALTH RELATED SERVICES
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services....

This requirement is not met as evidenced by:
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By POC date, Administrator will review regulation and conduct in-service training with staff and submit a training agenda with staff signatures to CCLD.
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Based on record review and interview, Licensee did not comply with the regulation above by not assisting C1 with dental appointment for fillings which poses a potential health and safety risk to persons in care.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3