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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200877
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:30:43 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
09/28/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210928111405
FACILITY NAME:NATIONAL PSYCHIATRIC CARE AND REHAB SERVICES INCFACILITY NUMBER:
079200877
ADMINISTRATOR:SHAMLY JOHALFACILITY TYPE:
772
ADDRESS:2181 TICE VALLEY BLVDTELEPHONE:
(925) 478-3795
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:12CENSUS: 10DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shamly Johal, Program DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff mismanaged resident's medications
Staff are not meeting resident's needs
INVESTIGATION FINDINGS:
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On 10/07/21 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit and met with Program Director (PD) to deliver the findings.

Allegation: Staff mismanaged resident's medications
Based on interviews and record reviews, prescribed and non-prescribed medications are all self-administered by clients with staff supervision. LPA reviewed clients’ medication administration records (MARs) which showed the daily medications/dosages of clients’ self-administered prescriptions, initialed by supervising staff on duty. LPA observed MARs records matched centrally stored medication logs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 3
Control Number 15-AS-20210928111405
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: NATIONAL PSYCHIATRIC CARE AND REHAB SERVICES INC
FACILITY NUMBER: 079200877
VISIT DATE: 10/07/2021
NARRATIVE
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Allegation: Staff are not meeting resident's needs

Based on interviews and record reviews, C2 did not communicate his medication needs to night shift staff on 09/25/21. LPA reviewed the non audio camera footage which showed C2 knocking on the medication room door at 12:57 AM on 09/25/21. Staff opened the medication room door at 12:58 AM where C2 was observed to have an exchange of words with staff. PD stated that C2 did not ask staff for medication that night and left the area. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3