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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201008
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:13:53 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
03/02/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220302102105
FACILITY NAME:TEMESCAL RESIDENTIAL CARE HOME CORP.FACILITY NUMBER:
079201008
ADMINISTRATOR:MELANIO, ANDRES JR JAGARAPFACILITY TYPE:
740
ADDRESS:4580 TEMESCAL COURTTELEPHONE:
(925) 813-5700
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 2DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Imelda Robles, Administrator
Gerllie Marin, Staff		TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Uncleared adults providing care to residents
Administrator does not afford a resident dignity and respect in their relationships by speaking non-English
INVESTIGATION FINDINGS:
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On 09/21/22 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit to deliver investigation findings, met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM.

Allegation: Uncleared adults providing care to residents
Investigation Finding: Substantiated
During visit, LPA observed staff (S2) was not present at the facility. ADM confirmed S2's employment was terminated on 04/01/22 due to uncleared status with the Department of Justice. Records reviewed dated 03/10/22 show S2 worked as a caregiver at the facility despite the fact that S2 was still uncleared with the CA Department of Social Services, Care Provider Management Bureau (CPMB).
Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 7
Control Number 15-AS-20220302102105
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
VISIT DATE: 09/21/2022
NARRATIVE
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A written notice was sent by CPMB to S2 on 09/01/21 regarding his criminal record exemption request. CPMB could not process the request because of missing information which must be submitted by S2 on 09/16/21. S2 failed to comply with this request.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Immediate civil penalty of $500 assessed due to employment of uncleared staff (S2).

Allegation: Administrator does not afford a resident dignity and respect in their relationships by speaking non-English
Investigation Finding: Substantiated
During investigation, LPA observed staff talking non-English to other staff at the facility in the presence of residents in care. Licensee confirmed with LPA that staff tend to talk in their native language when communicating with other staff in the presence of residents in care. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099 D.

Failure to submit proof of corrections (POCs) by plan of corrections due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20220302102105
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2022
Section Cited
CCR
87356(a)
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The Department shall notify a licensee to act immediately to terminate the employment of, remove from the facility or bar from entering the facility any person described in Sections 87356(a)(1) through (5) below while the Department considers granting or denying an exemption. Upon notification, the licensee shall comply with the notice.
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Deficiency cleared during visit. Administrator confirmed with LPA that S2 was terminated and disassociated from the facility on 04/01/22. LPA observed Guardian Portal show S2 separated from facility.
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This requirement was not met as evidenced by employment of uncleared staff at the facility which posed an immediate health and safety risk to residents in caare
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Immediate civil penalty of $500 accessed for employment of uncleared staff at the facility.
Type B
10/21/2022
Section Cited
CCR
87468.1(a)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately.
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By POC due date, administrator agrees to complete and submit to CCLD in-service staff retraining certifications regarding use of English language when communicating among staff and residents in care.
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This requirement was not met as evidenced by non English communication of staff with other staff in the presence of residents and family members which posed a potential health & safety risk to 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
03/02/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220302102105

FACILITY NAME:TEMESCAL RESIDENTIAL CARE HOME CORP.FACILITY NUMBER:
079201008
ADMINISTRATOR:MELANIO, ANDRES JR JAGARAPFACILITY TYPE:
740
ADDRESS:4580 TEMESCAL COURTTELEPHONE:
(925) 813-5700
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 2DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Imelda Robles, Administrator
Gerllie Marin, Staff		TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Administrator yelled at resident
Staff do not ensure resident a safe and healthful environment
Staff are not bathing residents
INVESTIGATION FINDINGS:
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On 09/21/22 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit to deliver investigation findings, met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM.

Allegation: Administrator yelled at resident
Investigation Finding: Unsubstantiated
During investigation, resident (R1) did not recall administrator yelling at him. He stated staff were always helpful and responsive to his needs. Other residents (R2, R3) stated staff never yelled or screamed at them. Administrator and staff denied yelling at any resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 7
Control Number 15-AS-20220302102105
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
VISIT DATE: 09/21/2022
NARRATIVE
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Allegation: Staff do not ensure resident a safe and healthful environment
Investigation Finding: Unsubstantiated
During investigation, residents (R1, R2, R3) stated they feel safe at the facility and that staff assists them with their activities of daily living (grooming, bathing, dressing, eating, medications, doctors’ appointments). LPA observed facility to be clean, sanitary and in good repair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Allegation: Staff are not bathing residents


Investigation Finding: Unsubstantiated
During investigation, residents (R1, R2, R3) stated staff assists them with their activities of daily living (bathing, grooming, dressing, eating, medications, doctors’ appointments). Residents confirmed with LPA that they were receiving their baths/showers from staff weekly. LPA observed residents appeared well groomed and clean. Staff stated residents are given baths or showers a minimum of twice per week or more if needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
03/02/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220302102105

FACILITY NAME:TEMESCAL RESIDENTIAL CARE HOME CORP.FACILITY NUMBER:
079201008
ADMINISTRATOR:MELANIO, ANDRES JR JAGARAPFACILITY TYPE:
740
ADDRESS:4580 TEMESCAL COURTTELEPHONE:
(925) 813-5700
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 2DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Andres "Jay" Melanio-Marquina, Administrator
Gerllie Marin, Staff		TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff have not refilled resident’s medication timely
Staff did not administer medications as prescribed
INVESTIGATION FINDINGS:
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On 09/21/22 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit to deliver investigation findings, met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM.

Allegation: Staff have not refilled resident’s medication timely
Investigation Finding: Unfounded
Review of residents’ (R1, R2, R3) centrally stored medication records show prescribed medications were filled and refilled by primary care physicians (05/04/21 thru 12/30/23) and administered by staff as confirmed by residents’ medication administration records. This department had investigated the complaint alleging that staff have not refilled residents’ medication timely. We have found that this allegation was unfounded, meaning that this allegation is without reasonable basis.
Continued on next page, LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20220302102105
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
VISIT DATE: 09/21/2022
NARRATIVE
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Allegation: Staff did not administer medications as prescribed
Investigation Finding: Unfounded
Review of residents’ (R1, R2, R3) centrally stored medication records and medication administration logs (dated December 2021, January 2022 thru March 2022) show residents’ medications were administered by staff as prescribed by their primary care physicians. Residents (R1, R2, R3) confirmed with LPA that staff assisted them with their medications daily. This department had investigated the complaint alleging that staff did not administer medications as prescribed. We have found that this allegation was unfounded, meaning that the allegation is without reasonable basis.

Exit Interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7