079200929-4-3-2023-15-AS-YFLS-CWKLKJ-20231013084937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200929
Report Date: 04/03/2023
Date Signed: 04/03/2023 02:45:50 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
10/03/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20221003094738

FACILITY NAME:	GREEN VALLEY CARE HOME		FACILITY NUMBER:	079200929
ADMINISTRATOR:	OSIA, MARJORIE		FACILITY TYPE:	740
ADDRESS:	116 VALDIVIA CIRCLE		TELEPHONE:	(925) 719-3589
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 6	DATE:	04/03/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Marjorie Osia, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Resident fell while in care due to lack of supervision.
Staff did not seek medical attention to resident in a timely manner.
Staff did not communicate with authorized representative of changes of resident's health status.
Staff did not ensure resident was utilizing medical devices.
Staff provided confidential information to an unauthorized person.
Staff did not safe guard resident's personal belongings.
Facility's door is in disrepair.
Facility do not follow covid protocols.

INVESTIGATION FINDINGS:

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On 4/3/2023 starting at 10:40 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. LPA was greeted by Care Staff, Caroline Olaniyi and LPA explained the purpose of the visit. Administrator, Marjorie Osia later arrived at 11:00 AM.

During the course of the investigation, LPA obtained information, reviewed records, collected documents, and interviewed staff and residents.

Allegation: Resident fell while in care due to lack of supervision.
On 4/2/23 at 11:10 AM, interview with S1 revealed that S2 and S3 were both on duty the day of the incident on 3/4/22. S1 stated S3 was assisting R1 in the bathroom and R1 slid off to the ground.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

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

Control Number 15-AS-20221003094738

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: GREEN VALLEY CARE HOME	FACILITY NUMBER: 079200929
	VISIT DATE: 04/03/2023

NARRATIVE

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During an interview with S2 and S3 on 4/3/22, S2 and S3 both denied of not remembering the incident. However, based on record review of R1's incident report, it indicates that a staff was assisting R1 in the bathroom when R1 during the incident.

Allegation: Staff did not seek medical attention to resident in a timely manner.
Based on interview with S1 and record review on 4/3/23, S3 assessed R1 and asked if R1 was in pain. R1 did not express of any pain so an ice pack was applied. When S1 arrived 10-15 minutes later, R1 expressed of pain so 9-1-1 was called.

Allegation: Staff did not communicate with authorized representative of changes of resident's health status.
LPA interviewed 3 staff and 3 of 3 staff stated that S1 is informed when there is a change in a resident's health condition, then S1 will then notify family. LPA discovered during an interview with S1 that S1 will text or call R1's responsible party to keep R1's responsible party updated. LPA observed a history of communication between S1 and resident's responsible party via text and progress notes.

Allegation: Staff did not ensure resident was utilizing medical devices.
However, interview with 2 staff revealed that staff assisted R1 with the hearing aid. However, R1 removes hearing aid. S1 stated staff will observe hearing aid on the chest or pillow, and staff will store hearing aid in the container to avoid misplacing it. Based on information obtained, facility was not assisting resident with nebulizer. However, there is no doctor's order for nebulizer.

Allegation: Staff provided confidential information to an unauthorized person.
Based on information obtained, facility staff disclosed of R1's passing over the phone with R1's family member. However, interview with S1 revealed that R1's family member contacted facility to notify staff about visiting R1, so staff disclosed to R1's family member of R1's passing.

REPORT CONTINUES ON 9099C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20221003094738

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: GREEN VALLEY CARE HOME	FACILITY NUMBER: 079200929
	VISIT DATE: 04/03/2023

NARRATIVE

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Allegation: Staff did not safe guard resident's personal belongings.
Based on information obtained, R1 was missing a hat. However, LPA reviewed R1's LIC 621 and did not observe the hat is listed to be entrusted to the facility.

Allegation: Facility's door is in disrepair.
Based on information obtained, a chair was being used to close the door. However, based on observation and interview with S1 on 4/3/2023, the door in room #2 is a French door. S1 stated the facility was instructed by the local fire department to remove the latch on top and bottom of the right door in case of an emergency. On 4/3/23, S1 demonstrated to LPA that left door of the French door latches to the right door when the lock is turned to the right.

Allegation: Facility do not follow covid protocols.
However, LPA interviewed 2 residents and 2 of 2 residents stated they observe staff wears their face coverings. 3 of 3 staff denied allegation.

Although the allegation may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations 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: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

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
10/03/2022 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20221003094738

FACILITY NAME:	GREEN VALLEY CARE HOME		FACILITY NUMBER:	079200929
ADMINISTRATOR:	OSIA, MARJORIE		FACILITY TYPE:	740
ADDRESS:	116 VALDIVIA CIRCLE		TELEPHONE:	(925) 719-3589
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 6	DATE:	04/03/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Marjorie Osia, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility did not provide a refund to authorized representatives.
Facility did not provide resident with notification of rent increases.

INVESTIGATION FINDINGS:

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On 4/3/2023 starting at 10:40 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. LPA was greeted by Care Staff, Caroline Olaniyi and LPA explained the purpose of the visit. Administrator, Marjorie Osia later arrived at 11:00 AM.

During the course of the investigation, LPA obtained information, reviewed records, collected documents, and interviewed staff and residents. It was alleged facility did not provide a refund to authorized representatives. Based on record review, a check was issued to R1's responsible party and check cleared on 8/18/2022.

REPORT CONTINUES ON 9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20221003094738

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: GREEN VALLEY CARE HOME	FACILITY NUMBER: 079200929
	VISIT DATE: 04/03/2023

NARRATIVE

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It was alleged facility did not provide resident with notification of rent increases. However, on 10/11/22, LPA obtained a copy of rate increase notification dated January 15, 2021.

This agency has investigated the complaint alleging facility did not provide a refund to authorized representatives and facility did not provide resident with notification of rent increases.. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5