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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200924
Report Date: 12/23/2021
Date Signed: 12/23/2021 03:52:32 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
12/17/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20211217090145
FACILITY NAME:A OHANA HOME FOR SENIORS, LLCFACILITY NUMBER:
079200924
ADMINISTRATOR:MALEKAMU, MARYFACILITY TYPE:
740
ADDRESS:1841 FLORENCE LNTELEPHONE:
(925) 698-1736
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 4DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Mary MalekamuTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not enforcing to wear PPE
INVESTIGATION FINDINGS:
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On 12/23/2021 Licensing Program Analyst (LPA) L. Ibo visited the facility to conduct initial 10 days visit . LPA explained that the reason for the visit that above complaint allegations of was filed . LPA met with Administrator Mary Malekamu.

During the complaint investigation LPA conducted document review & observation. LPA requested for physician’s report from Administrator. LPA observed that staff are not wearing mask during the visit.

Based on LPA interview and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of Appeal Rights and this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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-20211217090145
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: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2021
Section Cited
CCR
80072(a)
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Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
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Adminsitrator stated that she will trained all staff for proper PPE use, a copy of training topic and staff signature will need to send to CCL office by POC date.
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Based on observation LPA observed staff not wearing mask this possess potentia health and safety risk for residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3