079201020-12-10-2024-15-AS-KHOS-DBTSP5-20241210130236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201020
Report Date: 12/03/2024
Date Signed: 12/10/2024 12:23:18 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
09/25/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240925100114

FACILITY NAME:	DC CARE HOME		FACILITY NUMBER:	079201020
ADMINISTRATOR:	COULTER, DANIEL T.		FACILITY TYPE:	735
ADDRESS:	1444 OAK HAVEN COURT		TELEPHONE:	(925) 775-4290
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 4	DATE:	12/03/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Daniel Coulter, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff would not allow resident to have a visitor
Staff is selling marijuana to clients in care
Staff lock resident in a room
Staff does not ensure resident is accorded privacy

INVESTIGATION FINDINGS:

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On 12/10/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to amend investigation findings. LPA explained the purpose of the visit with ADM.

On 09/26/24, the department obtained the following documents from administrator – Client's roster with contact information, Staff roster with contact information, Personnel Record (LIC500) / Work Schedules, Admission agreements, ISP/IPP plans (last 12 months), Visitors logs (January thru September 2024), centrally stored medications & medication administration records (MARs), Incident reports.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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-20240925100114

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: DC CARE HOME	FACILITY NUMBER: 079201020
	VISIT DATE: 12/03/2024

NARRATIVE

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Allegation: Staff would not allow resident to have a visitor
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed client (C1) and administrator (ADM) who stated that C1’s responsible person (POA) instructed staff not to permit C1’s friend (RP) to visit or hang out with him due to their violent history from living together at a prior home that led to more poor choices, bad behaviors that compromised C1's health & safety. Review of emails between ADM and POA dated 09/26/24 confirmed that POA did not allow RP to visit or hang out with C1 for health and safety reasons. C1 stated he is allowed to have other friends visit him when approved by his POA. Other clients (C2, C3, C4) confirmed with LPA that family picks them up at the facility on several occasions. Although the allegation that staff would not allow resident to have a visitor may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated.

Allegation: Staff is selling marijuana to clients in care
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed clients (C1, C2, C3, C4) who stated that staff do not sell them marijuana or other drugs at the facility. Staff (ADM, S1, S2, S3) denied selling drugs to any clients. LPA observed during visits on 03/21/24 and 09/26/24 that clients (C1, C2, C3, C4) and facility surroundings did not smell of marijuana. Although the allegation that staff is selling marijuana to clients in care may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated.

Continued on next page, LIC 9099C pg1

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20240925100114

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: DC CARE HOME	FACILITY NUMBER: 079201020
	VISIT DATE: 12/03/2024

NARRATIVE

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Allegation: Staff lock resident in a room.
Investigation Finding: Unsubstantiated
During investigation, LPA observed each client’s bedrooms can only be locked from the inside. Clients (C1, C2, C3, C4) stated to LPA that they can lock and unlock their bedrooms from the inside whenever they want. Clients also stated that they are free to use the front door key of the facility as necessary. Staff denied locking any client in a room. Although the allegation that staff lock resident in a room may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated.

Allegation: Staff does not ensure resident is accorded privacy
Investigation Finding: Unsubstantiated
During investigation, clients (C1, C2, C3, C4) confirmed with LPA that staff do not follow them around. Staff stated that they respect each client’s privacy and personal rights. Clients confirmed with LPA that staff respects their privacy, that they can get their own mail, use the phone or other devices in private. LPA observed staff would knock on client’s bedroom doors and ask permission to come in during visits on 03/21/24 and 09/26/24. Although the allegation that staff does not ensure resident is accorded privacy may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, this allegation is unsubstantiated

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

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