079200924-4-13-2023-15-AS-KHOS-CRFNQ2-20230502103913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200924
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:40:50 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
12/17/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20211217090145

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:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mary Melakamu, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff left residents unattended
Three staff identified themselves as S2

INVESTIGATION FINDINGS:

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On 4/13/2023 starting at 10:10 AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct complaint investigation for the above allegations. Upon arrival, LPA was greeted by care staff (S3), LPA explained the purpose of the visit. At around 10:25 AM Administrator arrived and met with LPA. Facility has census of four (4).

LPA toured the facility inside and out. LPA observed two staff and the Administrator present at the facility.

REPORT CONTINUES ON 9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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
	VISIT DATE: 04/13/2023

NARRATIVE

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Allegation: Staff left residents unattended

Based on interview with residents and staff. Residents denied being left unattended. Staff stated that they check residents at least every 2-3 hours.

Allegation: Three staff identified themselves as S2.

Based on interview and records review, there is only one staff (S2) that is identified by that name. LPA conducted interview with residents in care, however residents was not sure if there are other staff identifying themselves are S2.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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