079201123-8-1-2022-15-AS-HHUL-CKMLJ3-20221028084715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201123
Report Date: 08/01/2022
Date Signed: 08/01/2022 01:17:22 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
04/04/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220404103547

FACILITY NAME:	LEE FAMILY CARE HOME #4		FACILITY NUMBER:	079201123
ADMINISTRATOR:	TUCKER, WILLIAM		FACILITY TYPE:	735
ADDRESS:	18 BROOKS CT		TELEPHONE:	(925) 354-2254
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 5	DATE:	08/01/2022
		UNANNOUNCED	TIME BEGAN:	10:56 AM
MET WITH:	William Tucker, Administrator and Maureen Lee, licensee.		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Neglect and lack of supervision sustaining severe injuries while in care
Staff did not prevent residents from engaging in physical altercation
Staff handled residents in a rough manner
Staff did not prevent resident from making threatening comments towards another resident

INVESTIGATION FINDINGS:

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On 08/01/2022 at 10:56AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Administrator, William Tucker and Maureen Lee, LPA explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, case manager, health providers, and complainant. C1’s medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed.

...Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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-20220404103547

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: LEE FAMILY CARE HOME #4	FACILITY NUMBER: 079201123
	VISIT DATE: 08/01/2022

NARRATIVE

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Allegation: Neglect and lack of supervision sustaining severe injuries while in care

On March 17, 2022 C1 and C5 had an altercation, C1 was physically aggressive towards C5. S2 tried to prevent the C1 from attacking C5 by blocking C1. S5 was protecting C5 from the room entrance way to protect him from being attacked. S1 arrived shortly after and was verbally calm down C1 and escort out of the facility without physical force. Medical records reviewed C1 sustained abrasion and elbow fracture requiring soft splint, however based on interview with clients revealed that they did not witnessed staff physical restrained or harm C1. Staff denied physically restraining or harming C1.

Allegation: Staff did not prevent residents from engaging in physical altercation

Based on investigation, S1, S2 and S5 was present during the physical altercation between C1 and C5. S1 & S2 verbally redirect C1 while S5 was with C5 protecting him from being attacked.

Allegation: Staff handled residents in a rough manner

Based on interview with clients revealed that they did not witnessed staff physical restrained or harm C1. Staff denied physically restraining or harming C1.

Allegation: Staff did not prevent resident from making threatening comments towards another resident

Based on investigation, S1, S2 and S5 was present during the physical altercation between C1 and C5, based on interview staff S2 and S5 talked to C1 and verbally redirect him from making threatening comments towards another resident.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC9099 (FAS) - (06/04)

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