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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200902
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:45:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
04/26/2023 and conducted by Evaluator Paris Watson
COMPLAINT CONTROL NUMBER: 15-AS-20230426163552
FACILITY NAME:NINA'S CARE HOMEFACILITY NUMBER:
079200902
ADMINISTRATOR:BROWN, JACQUELINEFACILITY TYPE:
740
ADDRESS:4272 GLAZIER CTTELEPHONE:
(510) 205-8491
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 2DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jacqueline Brown, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff left resident in the home unattended.
INVESTIGATION FINDINGS:
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On 5/3/2023 at 12:15 PM, Licensing Program Analysts (LPA) P. Watson arrived unannounced to conduct the 10-day initial complaint investigation for the above allegation. Administrator arrived to the facility at 1:02 PM. LPA met with Administrator, Jacqueline Brown and explained the purpose of the visit.

Allegation: Facility staff left resident in the home unattended.
Investigation Finding: Substantiated.

The morning of 5/3/2023 Administrator sent LPA an SIR self reporting that resident 1 (R1) was left unattended on 4/25/2023 due to staff 1 (S1) having a family emergency and Administrator being at a doctors appointment. During the initial10-day complaint visit, LPA toured facility, reviewed staff schedule and interviewed Administartor and resident 1 (R1).

Report continues on 9099 C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
04/26/2023 and conducted by Evaluator Paris Watson
COMPLAINT CONTROL NUMBER: 15-AS-20230426163552

FACILITY NAME:NINA'S CARE HOMEFACILITY NUMBER:
079200902
ADMINISTRATOR:BROWN, JACQUELINEFACILITY TYPE:
740
ADDRESS:4272 GLAZIER CTTELEPHONE:
(510) 205-8491
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 2DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jacqueline Brown, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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9
Facility staff did not lock medication cabinet.
INVESTIGATION FINDINGS:
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On 5/3/2023 at 12:15 PM, Licensing Program Analysts (LPA) P. Watson arrived unannounced to conduct the 10-day initial complaint investigation for the above allegation. Administrator arrived to the facility at 1:02 PM. LPA met with Administrator, Jacqueline Brown and explained the purpose of the visit.

Allegation: Facility staff did not lock medication cabinet.
Investigation Finding: Unsubstantiated.

During the initial10-day complaint visit, LPA toured facility and interviewed Administrator. LPA observed the medicine cabinet to be locked and inaccessible to residents.

Report continues on 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230426163552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NINA'S CARE HOME
FACILITY NUMBER: 079200902
VISIT DATE: 05/03/2023
NARRATIVE
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Based on LPA observations and interviews, the preponderance of evidence standard has not been met, therefore the above allegation, Facility staff did not lock medication cabinet, was found to be UNSUBSTANTIATED, meaning that 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.

No deficiencies cited. Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230426163552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NINA'S CARE HOME
FACILITY NUMBER: 079200902
VISIT DATE: 05/03/2023
NARRATIVE
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Based on LPA interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, Facility staff left resident in the home unattended, was found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) is being cited on the attached LIC 9099-D. A civil penalty of $500 is being assessed today.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20230426163552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NINA'S CARE HOME
FACILITY NUMBER: 079200902
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents...
(a) In addition to the rights listed in Section 87468.1....residents ..... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs.....
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Administrator will conduct training with staff and review regulation on importance of supervision and shift coverage to ensure residents are supervised at the facility.
Administrator will submit photographic proof of training to CCL by POC date.
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 Based on SIR review and interviews, the licensee did not ensure supervision for R1 on 4/25/2023 which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care
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A civil penalty of $500 is being assessed today.
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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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5