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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201071
Report Date: 09/19/2022
Date Signed: 09/19/2022 04:45:03 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
09/14/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220914163343
FACILITY NAME:PICADILLY HOME CAREFACILITY NUMBER:
079201071
ADMINISTRATOR:SANTOS, CHARLIEFACILITY TYPE:
735
ADDRESS:1221 PICADILLY LANETELEPHONE:
(925) 849-7743
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:4CENSUS: 4DATE:
09/19/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:CHARLIE SANTOS, Administrator TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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On 9/19/2022 at 11:20 AM, Licensing Program Analyst (LPA), L. Ibo conducted an unannounced visit. LPA met with S2, LPA called Administrator and informed him the purpose of the visit. At around 11:45AM, Administrator arrived at the facility.

During the course of investigation, the Department conducted interviews and collected pertinent documents such as but not limited to, Physician’s Report, Hospital Medical Records, and other facility documentation.

...Continued on LIC90999C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
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 2
Control Number 15-AS-20220914163343
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: PICADILLY HOME CARE
FACILITY NUMBER: 079201071
VISIT DATE: 09/19/2022
NARRATIVE
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Allegation—Resident sustained unexplained injuries while in care.

Based on interview and records review; On Sept. 14, 2022 staff noticed bruise on C1’s eyes, slight bruising and swelling on left side of his mouth. C1 was transported to the hospital/doctor's office on September 15, 2022. Based on records review C1 did not have any fracture, doctor’s note indicated that C1 had facial bruising due to unknown mechanism. Interview and records review indicated that C1 was diagnosed with seizure and repetitive body movements. Records review and interview indicated that one on one care staff was already in placed to supervise C1’s safety.

Based on the Department's observations, interviews conducted, records reviewed, and investigation, this allegation is found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted with Administrator. Copy of report was given.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2