079200827-5-12-2023-15-AS-KHOS-CTLL6P-20230710082906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200827
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:12:25 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
01/17/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20230117114726

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: 5	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Princess Nido, Caregiver		TIME COMPLETED:	03:33 PM

ALLEGATION(S):

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Staff did not provide residents medications as prescribed.

INVESTIGATION FINDINGS:

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On 05/12/2023 at 1:40 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Caregiver, Princess Nido and explained the purpose for the visit. LPA spoke with Administrator, Cecilia San Diego-Tomas via telephone. Administrator gave approval for caregiver to sign documents.

During the course of investigation, LPA interviewed 2 staff and 2 residents. LPA observed 1 resident in the living room and 4 residents in their bedroom. LPA received and reviewed the following documents: MAR for 6 residents, staff roster with contact numbers, physician's report, care plan, MAR, emergency information, facility progress notes for 3 residents R1, R2, R3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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-20230117114726

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: 05/12/2023

NARRATIVE

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Continue from LIC9099

Staff did not provide residents medications as prescribed.

RP stated that R1 was not given medication as prescribed. Based on interviews and information obtained from the MAR (medication administration record) shows that R1 received medications as prescribed, the MAR is signed by staff at the time medication is given. 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.

Exit interview conduct and a copy of report provided to Administrator.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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