079200883-2-17-2022-15-AS-KHOS-CDMHBG-20220419060308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200883
Report Date: 02/17/2022
Date Signed: 02/17/2022 10:45:14 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
04/27/2021 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20210427111417

FACILITY NAME:	LA CALLE HAVEN		FACILITY NUMBER:	079200883
ADMINISTRATOR:	LIPARDO, MELISSA		FACILITY TYPE:	735
ADDRESS:	1775 LA CALLE		TELEPHONE:	(925) 818-5890
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 6	DATE:	02/17/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Bernadette Lee, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are mismanaging resident's medication
Staff did not make sure resident was seen by a physician before being administered medication

INVESTIGATION FINDINGS:

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On 02/17/2022at 9:30AM, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Bernadette Lee, Administrator, and explained the reason for the visit.

During the course of the investigation, LPA P Singh conducted interviews with staff, Reporting Party (RP), obtained and reviewed documents. LPAs reviewed emails from physician, after summary visit and medical records..

On the allegation staff are mismanaging resident's medication. Based on interview with staff and record review of medical documents for R4, LPAs observed a medical document dated 4/12/21 that indicated there was a prescription given from the doctor for facility to follow for R4.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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-20210427111417

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: LA CALLE HAVEN	FACILITY NUMBER: 079200883
	VISIT DATE: 02/17/2022

NARRATIVE

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Continue from LIC 9099

On the allegation staff did not make sure resident was seen by a physician before being administered medication. LPA P. Singh obtained a copy of the after summary visit dated 4/12/2021 that indicated R4 was seen prior to medication being administered. LPA P. Singh also received email stating why R4 was referred and seen by the doctor.

Based upon the information obtained and interviews during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

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