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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201020
Report Date: 12/03/2024
Date Signed: 12/03/2024 04:02:28 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
12/02/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20241202160005
FACILITY NAME:DC CARE HOMEFACILITY NUMBER:
079201020
ADMINISTRATOR:COULTER, DANIEL T.FACILITY TYPE:
735
ADDRESS:1444 OAK HAVEN COURTTELEPHONE:
(925) 775-4290
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 4DATE:
12/03/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Daniel Coulter, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
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9
Staff did not administer medication as prescribed
Staff lost resident's medication
INVESTIGATION FINDINGS:
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3
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5
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On 12/03/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with administrator (ADM), interviewed staff & clients and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ADM.

On 09/26/24 & 12/03/24, 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), centrally stored medications & medication administration records (MARs), progress notes.

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)
Page: 1 of 4
Control Number 15-AS-20241202160005
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 did not administer medication as prescribed
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed clients (C1, C2, C3, C4) who confirmed with LPA that they receive their daily medications from staff as ordered by their primary care physicians (PCPs). Review of clients' medication administration records (MARS) from August 2024 until December 2024 show clients' daily medications are administered by staff as prescribed by their PCPs . Although the allegation that staff did not administer medication as prescribed 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 lost resident's medication
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM, S1, S2) who stated that client's (C2)'s medication box was stolen out of a U-haul truck when the contents spilled on the street along with their dirt bike equipment on 09/13/24. Staff obtained a refill of C2's medications on the same day. Review of C2's medication administration records showed all of C2's medications were refilled and administered to C2 by staff on 09/13/24. Although the allegation that staff lost resident's medication 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)
Page: 2 of 4