079200924-5-9-2024-15-AS-BFOG-D5HTVP-20240522150416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200924
Report Date: 05/09/2024
Date Signed: 05/09/2024 05:55:04 PM

Substantiated

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
05/03/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240503132850

FACILITY NAME:	A OHANA HOME FOR SENIORS, LLC		FACILITY NUMBER:	079200924
ADMINISTRATOR:	MALEKAMU, MARY		FACILITY TYPE:	740
ADDRESS:	1841 FLORENCE LN		TELEPHONE:	(925) 698-1736
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 4	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Mary 'Rose' Malekamu/Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff do not provide meals to residents in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 11:30 a.m. on this day, 5/09/24, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation and met with staff, Rey Usaraga. Mary 'Rose' Malekamu, admnistrator, arrived after several minutes. LPA informed the reason for visit.

During the course of investigation, LPA reviewed resident records, and interviewed staff, residents and reporting party (RP). LPA also interviewed witness (W1) who is not related to any residents and staff and has visited the facility.

It was alleged that the facility staff has guests regularly and residents wait until guests finish eating lunch before the resident are given meals.

..............continued next page (page 2)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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 5

Control Number 15-AS-20240503132850

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: A OHANA HOME FOR SENIORS, LLC	FACILITY NUMBER: 079200924
	VISIT DATE: 05/09/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

RP stated that RP went to the facility in April 2024 and observed the residents were still in the middle at 1:30 pm. RP stated that one of the residents was upset because they are given lunch late,

W1 stated that W1 was at the facility in April 2024, day other than the day RP was at the facility. W1 stated she was at the facility at 11:00 am and residents were not served lunch until the time she left at 2:00 pm.

Based on information gathered. the preponderance of evidence has been met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty,

Deficiency and plan and proof of correction were discussed with the administrator,

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20240503132850

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: A OHANA HOME FOR SENIORS, LLC	FACILITY NUMBER: 079200924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/23/2024 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ......	1 2 3 4 5 6 7	Administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/23/24.
	8 9 10 11 12 13 14	........to meet their needs. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above in not providing meals to residents in timely manner which poses a potential health and/or personal rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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
05/03/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240503132850

FACILITY NAME:	A OHANA HOME FOR SENIORS, LLC		FACILITY NUMBER:	079200924
ADMINISTRATOR:	MALEKAMU, MARY		FACILITY TYPE:	740
ADDRESS:	1841 FLORENCE LN		TELEPHONE:	(925) 698-1736
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 4	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Mary 'Rose' Malekamu/Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff does not ensure proper restrooms access is available to residents in care.

-Individuals in the home pose a risk to residents in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations and met with staff, Rey Usaraga. Mary 'Rose' Malekamu, admnistrator, arrived after several minutes. LPA informed the reason for visit.

During the course of investigation, LPA review resident records, and interviewed staff, residents, reporting party (RP), and resident's family member (FM).

Allegation: Staff does not ensure proper restrooms access is available to residents in care.
RP stated that resident (FR) brought to RP's attention that facility staff has guest regularly and residents' restrooms are sometimes occupied by guests causing residents to have to wait for their use.

.....continued on 9099C(page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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-20240503132850

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: A OHANA HOME FOR SENIORS, LLC	FACILITY NUMBER: 079200924
	VISIT DATE: 05/09/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA tried to reach FR several times but unsuccessful. LPA interviewed 3 residents and one of the 3 residents stated there's no issue on the restrooms. LPA was not able get information from the other 2 residents due to their medical condition/diagnosis. LPA also interviewed FM who stated the resident never brought to her attention any issue about the restroom. FM further stated that when she comes and visit, she's able to use the restroom.

Allegation: Individuals in the home pose a risk to residents in care
RP stated that resident (FR) brought to RP's attention that facility staff has guest regularly especially on weekends, and hang out on the lower level of the home until the late hours of the night socializing, and watching television loudly. Furthermore, the guests are staying overnight causing a disturbance to residents' sleep. One night, the resident was awoken by one of the guests entering the resident's room unannounced in the middle of the night.

LPA tried to reach FR several times but unsuccessful. LPA interviewed 3 residents and one of the 3 residents stated not being bothered by the presence of the guests and no incident of staff's guest entering the resident's room. LPA was not able get information from the other 2 residents due to their medical condition/diagnosis. LPA also interviewed FM who stated the resident never brought to her attention any issue staff's guest entering the resident's room nor have observed staff's guests hanging out late at night.

Based on information obtained, the allegations are closed as 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.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5