079200827-3-3-2021-15-AS-HHUL-BYSQPM-20210304112054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200827
Report Date: 03/03/2021
Date Signed: 03/03/2021 04:41:01 PM

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
04/07/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200407133619

FACILITY NAME:	LOVING HANDS CARE HOME LLC		FACILITY NUMBER:	079200827
ADMINISTRATOR:	SAN DIEGO-TOMAS, CECILIA		FACILITY TYPE:	740
ADDRESS:	748 VAQUEROS AVE		TELEPHONE:	(510) 245-3738
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY:	6	CENSUS: 4	DATE:	03/03/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Cecilia San Diego-Tomas, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not give resident notice of rent increase.

Staff is not allowing resident to remove her bed once she moved out.

INVESTIGATION FINDINGS:

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On 03/03/2020, Licensing Program Analyst (LPA) L. Hall called the facility to deliver the complaint findings for the above allegations. LPA spoke with Administrator, Cecilia San Diego - Tomas. LPA explained due to the present shelter in place order by the Governor, the notification of the complaint is being done over the phone.

This agency has investigated the complaint alleging staff did not give resident notice of rent increase. Based on documents collected, there is no evidence indicating the facility provided Resident #1 (R1) notice of increase. S1 made a change to R1’s original admission agreement without providing an official notice or justification to R1’s rent increase.

Report continues on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

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 5

Control Number 15-AS-20200407133619

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: LOVING HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
	VISIT DATE: 03/03/2021

NARRATIVE

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This agency has investigated the complaint alleging staff is not allowing resident to remove bed once moved out. Based on records, S1 kept the bed and did not allow the FM1 to take R1’s bed when she moved out. However, S1 did not provide or offer any options for the FM1 to remove the bed from the facility.

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20200407133619

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: LOVING HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/10/2021 Section Cited HSC 1569.655(a)	1 2 3 4 5 6 7	1569.655... residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures ... the licensee shall provide no less than 60 days'	1 2 3 4 5 6 7	Licensee agreed to review regulations regarding notice of rate increase and submit written self certification letter to CCLD by POC date.
	8 9 10 11 12 13 14	Based on LPA observation, licensee did not comply with the section cited above in 1569.655(a). LPA observed licensee did not provide a notice of rent increase to R1 and R1's responsible party which poses as a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/10/2021 Section Cited CCR 87217(i)	1 2 3 4 5 6 7	87217(i) Safeguards for Resident Cash, Personal Property, and Valualables:Upon discharge of a resident, all cash resources, personal property and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident... This requirement was not met as evidence by.	1 2 3 4 5 6 7	Licensee agreed to contact RP to make arrangements for bed and review regulations regarding safeguards for resident cash, personal property, and valuables and submit written self certification letter to CCLD by POC date.
	8 9 10 11 12 13 14	Based on LPA observation, licensee did not comply with the section cited above in 87217(i). LPA observed licensee did not provide options or allow R1 to pick up personal property once discharged from the facility which poses a potential personal right risks to residents in care.	8 9 10 11 12 13 14

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/07/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200407133619

FACILITY NAME:	LOVING HANDS CARE HOME LLC		FACILITY NUMBER:	079200827
ADMINISTRATOR:	SAN DIEGO-TOMAS, CECILIA		FACILITY TYPE:	740
ADDRESS:	748 VAQUEROS AVE		TELEPHONE:	(510) 245-3738
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY:	6	CENSUS: 4	DATE:	03/03/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Cecilia San Diego-Tomas, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not give resident a copy of the admission agreement.

Facility is infested with roaches.

INVESTIGATION FINDINGS:

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On 03/03/2020, Licensing Program Analyst (LPA) L. Hall called the facility to deliver the complaint findings for the above allegations. LPA spoke with Administrator, Cecilia San Diego - Tomas. LPA explained due to the present shelter in place order by the Governor, the notification of the complaint is being done over the phone.

During the course of investigation, LPA conducted interviews and collected documentation in relation to the complaint. Based on interview conducted, Family Member #1 (FM1) stated the facility did not provided admission agreement to him. However, Staff #1 (S1) stated the facility provided a copy to FM1. LPA observed admission agreement was completed and signed by FM1. However, LPA was not able to determine if a copy of the admission agreement was provided to FM1.Based on information obtained, the above allegation is unsubstantiated.

Report continues on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20200407133619

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: LOVING HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
	VISIT DATE: 03/03/2021

NARRATIVE

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Facility is infested with roaches

This agency has investigated the complaint alleging facility is infested with roaches. Based on annual visit on 01/06/2020, LPA observed roaches found on the kitchen wall. FM1 stated roaches were in R1’s bedroom, bedroom drawer, and bathroom. However, facility hired Terminex service on 01/07/2020 and 03/05/2020. S1 stated they are working on a solution with Terminex.

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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC9099 (FAS) - (06/04)

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