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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200861
Report Date: 07/03/2024
Date Signed: 07/03/2024 10:11:07 AM

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
06/28/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240628143352
FACILITY NAME:GAENOR HOME INCFACILITY NUMBER:
079200861
ADMINISTRATOR:NORIEGA, DIONEILFACILITY TYPE:
735
ADDRESS:1754 SATTLER DRTELEPHONE:
(925) 332-7907
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 6DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ernesto Ortigas, CaregiverTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff is overmedicating clients
INVESTIGATION FINDINGS:
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 On 07/03/2024 at 08:50AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with staff Ernesto Ortigas. Administrator Dionel Noriega was called and designated Ernesto to sign off on the report.

During the initial 10-day complaint visit LPA collected the following documents: medication list for all residents, medication logs for all residents, letter from concervator for R1, visitaton log for R1, IPP for R1.

On the allegation, Facility staff is overmedicating clients.
LPA reviewed residents (R1, R2, R3, R4, R5, R6)’s medications/dosages logs. LPAs observed medications/dosages matched residents’ corresponding medication administration records (MARs). Staff (S1, S2) confirmed with LPA that they administer residents’ daily medications as prescribed and records them on the MARs.
Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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-20240628143352
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: GAENOR HOME INC
FACILITY NUMBER: 079200861
VISIT DATE: 07/03/2024
NARRATIVE
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...Continued from 9099

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2