079200925-10-17-2022-15-AS-KHOS-CM5Q4V-20221215105058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200925
Report Date: 10/17/2022
Date Signed: 10/17/2022 03:17:01 PM

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
12/04/2020 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20201204150609

FACILITY NAME:	OAKMONT OF CONCORD		FACILITY NUMBER:	079200925
ADMINISTRATOR:	ANGELES STICKA		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	0	CENSUS: 89	DATE:	10/17/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Avon Nguyen, Executive Director		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to give resident medications as prescribed
Staff falsified resident's records

INVESTIGATION FINDINGS:

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

On 10/17/2022 Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the above allegation. LPA met with Avon Nguyen, Executive director and explained the purpose of the visit.

Allegation: Staff failed to give resident medications as prescribed

During the course of investigation, LPA could not conduct a medication count since resident no longer at the facility. Based on interviews, medication was destructed after resident leave the facility. Based on reports there were no evidence of missing medication from residents in care.

...continued to LIC9099C...

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: 10/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

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 2

Control Number 15-AS-20201204150609

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: OAKMONT OF CONCORD	FACILITY NUMBER: 079200925
	VISIT DATE: 10/17/2022

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

Allegation: Staff falsified resident's records

Based on interview, staff denied falsifying the documents; staff interviews also stated that narcotics are being audited at least 3x day with at least two staff (med-tech & wellness nurse) and information are being verified by at least two staff.

Based on observations, interviewed conducted, and records reviewed, the above allegations have been found to be UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interview conducted with Executive Director Avon Ngueyn. Copy of report provided via email PDF.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2