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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200977
Report Date: 05/13/2025
Date Signed: 05/13/2025 04:23:33 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
10/25/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241025113739
FACILITY NAME:WE CARE ELDERLY CAREFACILITY NUMBER:
079200977
ADMINISTRATOR:WHITE, BRITTANY DFACILITY TYPE:
740
ADDRESS:4155 BELL AVETELEPHONE:
(510) 375-4460
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:8CENSUS: 4DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jeremey Tatum, Care StaffTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not administer medication(s) to resident(s) as prescribed.
INVESTIGATION FINDINGS:
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On 05/13/25 around 3:30 PM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to deliver the findings for the above allegation. LPA met with Jeremey Tatum, Care Staff, and explained the purpose of the visit.

During the course of the investigation and visits, LPA toured the facility, requested an updated staff and resident roster, reviewed staff schedules, ID/Emergency Information, Unusual/Incident Reports (UIRs), Physician’s Reports (LIC602s), Death Reports (DR), conducted interviews, and reviewed emails pertaining to Residents (R1, R2, R3, R4, R5, R6, R7). LPA reviewed R1’s Admissions Agreement, interviewed Staff (ADM, S1, S2, S3) and Witnesses (W1, W3, W4).

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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 6
Control Number 15-AS-20241025113739
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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
VISIT DATE: 05/13/2025
NARRATIVE
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...continued from LIC9099.

On 09/18/24, R1’s physician prescribed the application of Neosporin to R1’s left ear twice daily until healed. R1’s ear appeared to be red in color and chaffed from the photo W1 presented. On 10/30/24, W1 provided the prescription, additional photos and a medication discharge list dated 10/22/24 for R1. R1’s CSMDR and Medication Discharge list did not include Neosporin; furthermore, R1’s LIC602 additional notes states to notify MD if R1 experiences the above symptoms. Interviews and records reviewed revealed that R2’s medication discharge list dated 12/20/24 did not include R2’s remaining Oxycodone. R2 stated that he/she should have had about 20-25 pills remaining. R2 stated that S1 said the medication had to be thrown away, was wet or something like that. S1 submitted an LIC624 to CCLD on 12/19/24 stating the pills fell on the floor and had been documented for destruction. S1 did not indicate the number of pills destroyed on the LIC624. S1 documented what appeared to be 22 pills were disposed on 12/19/24. R2 stated that she was not provided with any remaining pills or the prescription bottle, not even the wet prescription bottle and top.

Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and a copy of this report provided to Jeremey Tatum, Care Staff

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/25/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241025113739

FACILITY NAME:WE CARE ELDERLY CAREFACILITY NUMBER:
079200977
ADMINISTRATOR:WHITE, BRITTANY DFACILITY TYPE:
740
ADDRESS:4155 BELL AVETELEPHONE:
(510) 375-4460
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:8CENSUS: 4DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jeremey Tatum, Care StaffTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Questionable Deaths.
Licensee does not ensure that residents are provided adequate care and supervision while in care Administrator is not on the facility premises a sufficient number of hours.
Staff did not allow resident to have possession of their personal belongings.
Staff do not respond to residents' requests for assistance in a timely manner.
INVESTIGATION FINDINGS:
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On 05/13/25 around 3:30 PM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to deliver the findings for the above allegation. LPA met with Jeremey Tatum, Care Staff, and explained the purpose of the visit. On 06/06/25, LPA amended the report to correct the unsubstantiated allegations.

During the course of the investigation and visits, LPA toured the facility, requested an updated staff and resident roster, reviewed staff schedules, ID/Emergency Information, Unusual/Incident Reports (UIRs), Physician’s Reports (LIC602s), Death Reports (DR), conducted interviews, and reviewed emails pertaining to Residents (R1, R2, R3, R4, R5, R6, R7). LPA reviewed R1’s Admissions Agreement, interviewed Staff (ADM, S1, S2, S3) and Witnesses (W1, W3, W4).

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20241025113739
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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
VISIT DATE: 05/13/2025
NARRATIVE
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...continued from LIC9099A

Allegations: Unsubstantiated

Questionable Deaths.

Two deaths occurred around the same time at the facility on 10/02/24 and 10/13/24. R6 and R7 both had preexisting illnesses and later a change in their existing conditions. R6’s death was reported to the facility by R6’s family after being admitted to the hospital on 09/26/26 for pneumonia. On 10/01/24, W5 confirmed that S1 requested hospice care for R7 who exhibited signs of declining health due to increased falls, lack of speech, and decreased appetite. R7 was diagnosed with failure to thrive before S1 was able to obtain hospice care services at the facility.

Licensee does not ensure that residents are provided adequate care and supervision while in care.

The allegation refers to R1 being unattended while using the bathroom at the facility. LPA attempted to interview W2 who witnessed the allegation. LPA confirmed W2’s contact information with W1. LPA attempted to make phone contact with W2 on two additional occasions throughout the investigation and was unsuccessful. R1’s LIC624 dated 09/20/24 states that R1 is unable to bathe, groom or care for his/her own toileting. LPA was unable to confirm or deny the allegation occurred. S2 stated that he/she was not aware of any problems and did not know R1 would not be returning to the facility when R1 was picked up on 10/16/24. S1 reported that W1 has never called or answered phone calls from the facility, nor did W1 verbalize having and grievances about the services rendered. As of today’s date, LPA has not been successful in contacting W2.

Administrator is not on the facility premises a sufficient number of hours.

LPA reviewed the facility’s staffing scheduled and confirmed S1 scheduled hours at the facility. S1 stated, “All staff collaborate to cover shifts that are open to ensure proper coverage for care of residents based on census.” If S1 is not available upon arrival when LPA is conducting a case management, complaint or inspection visit, S1 will arrive in 10-15 minutes upon request.

Continued on LIC9099...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20241025113739
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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
VISIT DATE: 05/13/2025
NARRATIVE
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...continued from 9099C.

Staff did not allow resident to have possession of their personal belongings.

Interviews revealed that R1, R2, R3, R4, R5 and W3 did not have any complaints of not being in possession of resident’s personal belonging. LPA toured R2’s room, closet and dresser drawers. R2 was in possession of his/her shoes, clothing, toiletries items and memorabilia that was displayed on the walls. R3 stated that he/she loves art, has far too much, and had what R3 needed at the facility. W3 stated that R4 doesn’t always make the best choices, wants to move, but hasn’t had any other complaints from R4 or R5.

Staff do not respond to residents' requests for assistance in a timely manner.

After review of complaint and interviews with W1, W3, S1, S2, S3, R2 and R3, there was no mention of staff not responding to residents’ request for assistance in a timely manner. R3 stated. “There were sometimes I would have said, “I would like to be changed” but they were kind and would bring me things.” W4 stated he/she was not aware of any problems or issues at the facility; W4 speaks with R2 about once a month.

Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Jeremey Tatum, Care Staff

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20241025113739
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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2025
Section Cited
CCR
87465(e)
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87465 Incidental Medical and Dental Care e) For every prescription...the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
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Licensee/ADM to provide CCLD vendored training (TBD) to all staff and provide proof by POC date.
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 -This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above by not properly administering medication and documenting it's destruction.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6