079200787-8-13-2024-15-AS-KHOS-D9FJA9-20240925065223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200787
Report Date: 08/13/2024
Date Signed: 08/13/2024 02:44:01 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
08/06/2024 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20240806083244

FACILITY NAME:	DIANA'S CARE HOME		FACILITY NUMBER:	079200787
ADMINISTRATOR:	REANO-AQUINO, GRACE		FACILITY TYPE:	740
ADDRESS:	27402 MANON AVENUE		TELEPHONE:	(510) 786-9982
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	35	CENSUS: 35	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Grace Reano- Aquino, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not prevent resident from physically abusing another resident
Staff are not providing adequate food service to resident
Staff took resident’s phone as retaliation
Staff are not ensuring resident is seen by medical doctors
Staff did not safeguard resident’s personal belongings
Staff did not allow resident to call CCL to file a complaint
Staff does not treat resident with dignity and respect
Staff are not meeting residents needs

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo arrived unannounced to conduct investigation on the above allegation. LPAs explained the purpose of the visit to administrator (AD) Grace Reano- Aquino.

Allegation: Staff did not prevent resident from physically abusing another resident: Unsubstantiated

During the course of investigation LPAs conducted residents’ files reviewed, interviews residents, and staffs. It was alleged that Staff did not prevent resident from physically abusing another resident, however after LPAs interviewed with R1, R1 stated “the resident that tried to hurt me is not here anymore, and that no one witness or sees it”. LPAs interviewed 4 staff and 4 out of 4 stated that they have never witness, nor heard any incidents of residents physically abusing another resident. LPAs interviewed resident, R2 stated that R2 have not witness any residents physically abused. Therefore, the allegation is unsubstantiated.

Allegation: Staff are not providing adequate food service to resident: Unsubstantiated

During the course of investigation LPAs conducted interviews with residents, and staffs. Residents stated that the facility gives residents different varieties food choices. Staffs stated that food are provided to residents are by their choices, but some residents have special foods diet, so we have to follow the doctor orders. Therefore, the allegation is unsubstantiated.

Report continues on LIC 9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240806083244

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: DIANA'S CARE HOME	FACILITY NUMBER: 079200787
	VISIT DATE: 08/13/2024

NARRATIVE

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Allegation: Staff took resident’s phone as retaliation: Unsubstantiated

During the course of investigation LPAs reviewed R1 files indicated that R1 is diagnose with schizo affective. LPAs interviewed 4 staff 4 out of 4 stated that R1 is not medication compliance. R1 stated “My mind is clear, and I don’t want to take any medication”. S1 stated R1 phone is with the facility due to R1 excessive calling the police. LPAs confirmed with R1 family member that they are aware that R1 phone is with the facility staff. LPAs noted that R1 is conserved by San Mateo County Public Guardian, and R1 conservator/ family members asked the facility to keep R1 phone, which are not to retaliation. Therefore, the allegation is unsubstantiated.

Allegation: Staff are not ensuring resident is seen by medical doctors: Unsubstantiated

During the course of investigation LPAs conducted residents’ files reviewed, and staffs interviewed. After reviewing R1 records of doctor visit/ notes showed R1 doctor seen R1 at the facility once a month, and as needed. S1 and S2 indicated at time R1 doesn’t want to see R1 doctor. Therefore, the allegation is unsubstantiated.

Allegation: Staff did not safeguard resident’s personal belongings: Unsubstantiated

During the course of investigation LPAs conducted interviewed with R1, and staffs interviewed. R1 stated that some of R1 paper are missing. LPAs reviewed LIC 621 and when asked R1 regrading the missing paper LPAs observed that R1 was not able to explain what exactly what was missing in R1 belonging. LPAs observed R1 pull out papers from different folders indicating that R1 believes that R1 paper is missing. 4 out of 4 staffs indicated that R1 is very specific about R1 belonging, therefore staff is not able to touch R1 belonging without R1 being present. Therefore, the allegation is unsubstantiated.

Report continues on LIC 9099c...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20240806083244

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: DIANA'S CARE HOME	FACILITY NUMBER: 079200787
	VISIT DATE: 08/13/2024

NARRATIVE

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Allegation: Staff did not allow resident to call CCL to file a complaint: Unsubstantiated

During the course of investigation LPAs conducted interviewed with R1, and staffs interviewed. R1 stated that staff didn’t let R1 used the phone when someone is in used of the facility phone. S1 and S2 stated that “we never said no to R1 only when the phone is being used by other residents, so we asked/ explained to R1 that R1 have to wait”. S1 and S2 stated that majority of the time R1 is the one that used the facility phone. Therefore, the allegation is unsubstantiated.

Allegation: Staff does not treat resident with dignity and respect: Unsubstantiated

During the course of investigation LPAs conducted interviewed residents and staffs. All indicated that staffs treated residents with respect and do not put any residents down. 4 out of 4 staffs states “they have not seen, witness, heard, or themselves disrespect or put any residents down”. R3 stated that “I get treated with respect here”. Therefore, the allegation is unsubstantiated.

Allegation: Staff are not meeting residents needs: Unsubstantiated

During the course of investigation LPAs conducted residents and staff’s interview. 4 out of 4 staff indicated that we observed residents and look at the needs and service plan to assist residents. Residents indicated that the staff at the facility meet all their needs. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview is conducted, and this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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