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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200834
Report Date: 08/17/2021
Date Signed: 08/17/2021 11:45:15 AM



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
10/28/2019 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20191028135815
FACILITY NAME:TERRACE VIEW ASSISTED LIVINGFACILITY NUMBER:
079200834
ADMINISTRATOR:MICHAELSON, MANJULAFACILITY TYPE:
740
ADDRESS:2828 TERRACE VIEW AVETELEPHONE:
(925) 354-0403
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:3CENSUS: 1DATE:
08/17/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Manjula Michaelson, AdministratorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Licensee failed to safeguard resident confidential information.
INVESTIGATION FINDINGS:
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On 8/17/2021 at 11:00AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegations. LPA met with Manjula Michaelson, Administrator, and explained the reason for the visit.

During investigation, the Licensee (S1), Reporting Party (RP), subject resident (R1) & one additional resident (R2) were interviewed; and the resident files for R1 and R2 were reviewed. The RP and S1 both had photos of a check from the RP and R1 that contained R1’s primary mailing address. S1 confirmed having shown this check to an unrelated third party.

Continued from LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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-20191028135815
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: TERRACE VIEW ASSISTED LIVING
FACILITY NUMBER: 079200834
VISIT DATE: 08/17/2021
NARRATIVE
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Continued from LIC9099.

The Department has investigated this allegation and based upon interviews and records review, the allegation is Substantiated, meaning that the preponderance of evidence has been met. Deficiency cited per the California Code of Regulations, Title 22, Failure to correct the deficiency by the POC date may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20191028135815
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: TERRACE VIEW ASSISTED LIVING
FACILITY NUMBER: 079200834
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2021
Section Cited
HSC
1569.269(a)(3)
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1569.269 Enumerated rights; severability (a) Residents... shall have all of the following rights: (3)To confidential treatment of their records and personal information... This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.
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Licensee did not comply with the section cited above by keeping Resident's record confidential, which imposes a potential health and safety risk for person 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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
10/28/2019 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20191028135815

FACILITY NAME:TERRACE VIEW ASSISTED LIVINGFACILITY NUMBER:
079200834
ADMINISTRATOR:MICHAELSON, MANJULAFACILITY TYPE:
740
ADDRESS:2828 TERRACE VIEW AVETELEPHONE:
(925) 354-0403
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:3CENSUS: 1DATE:
08/17/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Manjula Michaelson, AdministratorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Licensee inappropriately disciplines resident(s) in care

Licensee failed to provide adequate care for resident.
INVESTIGATION FINDINGS:
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On 8/17/2021 at 11:00AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegations. LPA met with Manjula Michaelson, Administrator, and explained the reason for the visit.

During investigation, the Licensee (S1), Reporting Party (RP), subject resident (R1) & an additional resident (R2) were interviewed; and the resident files for R1 and R2 were reviewed. S1 denied that R1 had not been properly bathed or groomed; and denied any abuse towards R2. Upon direct observation, R2 had no marks, bruising, scratches, or scrapes of any kind; and was appropriately groomed and attired. R2 did not state or indicate any issues with residing at the facility. R1 was unable to address the allegations during interview. There was no neutral information nor direct neutral witnesses identified that could collaborate or deny either of these two allegations.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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-20191028135815
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: TERRACE VIEW ASSISTED LIVING
FACILITY NUMBER: 079200834
VISIT DATE: 08/17/2021
NARRATIVE
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Continued from LIC9099.

The Department has investigated this complaint and although the allegations may have happened or are valid, there is not a preponderance of evidence that the allegations did or did not occur. Therefore, the allegations are Unsubstantiated.

Exit interviewed conduct and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5