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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200784
Report Date: 04/05/2024
Date Signed: 04/05/2024 12:29:10 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
03/28/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240328084742
FACILITY NAME:LAFAYETTE GARDENSFACILITY NUMBER:
079200784
ADMINISTRATOR:SAXENA, MEERANFACILITY TYPE:
740
ADDRESS:3486 MONROE AVENUETELEPHONE:
(408) 623-2859
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 6DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Meeran Saxena, AdminstratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Administrator accepted resident without proper paperwork or signatures from the authorized representative
INVESTIGATION FINDINGS:
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On this day at around 10:00 am, Licensing Program Analysts (LPAs) K. Nguyen and L. Holmes arrived unannounced to conduct investigation on the above allegations. LPAs met with caregiver Annie Perez and explained the purpose of visit. LPAs informed Administrator Meeran Saxena the purpose of visit. Administrator arrived at the facility at a later time.

During the course of investigation, LPAs interviewed Administrator Meeran regrading the above allegation. Administrator confirmed to LPAs that she does not have R1 Physician's Report, Admission Agreement.

Based on interview conducted, Resident 1 (R1) has a diagnosis of Dementia and trying to get in contact with R1 POA to get all the documentation sign. Documents that was being provided is from the previous facility and not for this facility.

Based on LPA interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22. Deficiencies are being cited on the attached LIC 9099D.

Exit interview was conducted with Meeran. Appeal Rights was provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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 2
Control Number 15-AS-20240328084742
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: LAFAYETTE GARDENS
FACILITY NUMBER: 079200784
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2024
Section Cited
CCR
87507
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87507 Admission Agreements
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By POC date Administrator agree to obtained R1 admission agreement, and all require document sign by R1 representative.
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Based on interview conducted, Resident 1 (R1) has a diagnosis of Dementia and trying to get in contact with R1 POA to get all the documentation sign. Documents that was being provided is from the previous facility and not for this facility.
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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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2