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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201188
Report Date: 04/07/2023
Date Signed: 04/07/2023 06:48:28 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
04/03/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230403164320
FACILITY NAME:EL REY HOME, THEFACILITY NUMBER:
079201188
ADMINISTRATOR:HAMILTON, LORELLFACILITY TYPE:
740
ADDRESS:2717 EL REY STREETTELEPHONE:
(925) 501-0235
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:3CENSUS: 1DATE:
04/07/2023
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Lorell Hamilton, AdminstratorTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Staff abandoned resident at hospital
Staff did not follow proper eviction procedures for resident
INVESTIGATION FINDINGS:
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On 04/07/23 at 5PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), conducted interviews and record reviews and delivered investigation finding to ADM. LPA explained the purpose of the visit with administrator.

Allegation: Staff abandoned resident at the hospital
Investigation Finding: SUBSTANTIATED
On 04/07/23, LPA confirmed with administrator (ADM) that resident (R1) was transported by ambulance to the hospital on 04/03/23 where she was diagnosed and treated for constipation. ADM stated that she did not pick up R1 from the hospital because she has verbally communicated with R1’s authorized representative (POA) for 2 weeks after admission in early March that R1 needed to be relocated to another facility due to higher level of care needs. Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
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 3
Control Number 15-AS-20230403164320
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: EL REY HOME, THE
FACILITY NUMBER: 079201188
VISIT DATE: 04/07/2023
NARRATIVE
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On 04/03/23. LPA confirmed with hospital staff (SW) that ADM did not pick up R1 who was waiting for pick-up at the hospital that day.

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) that staff abandoned resident at the hospital was found to be substantiated.

Allegation: Staff did not follow proper eviction procedures for resident
Investigation Finding: SUBSTANTIATED
During visit, LPA confirmed with administrator (ADM) that she did not issue a written eviction notice to resident (R1) and her authorized representative (POA). ADM confirmed with LPA that R1’s personal belongings were removed from the facility on 04/03/23 and that R1 did not return to the facility from the hospital.

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) that staff did not follow proper eviction procedures for resident was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction 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.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230403164320
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: EL REY HOME, THE
FACILITY NUMBER: 079201188
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited
CCR
87465(a)(2)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
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By POC due date, Administrator agreed to complete and submit to CCLD in-service staff retraining certifications on Incidental Medical and Dental Care to ensure compliance with Title 22 Section 87465 (a) (2).
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This requirement was not met as evidenced by staff not picking up resident from the hospital after treatment which posed a potential health & safety risk to resident in care.
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Type B
04/28/2023
Section Cited
CCR
87724(a)
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By POC due date, Administrator agreed to complete and submit to CCLD in-service staff retraining certifications on Incidental Medical and Dental Care to ensure compliance with Title 22 Section 87465 (a) (2).
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By POC due date, Administrator agreed to complete and submit to CCLD in-service staff retraining certifications on Incidental Medical and Dental Care to ensure compliance with Title 22 Section 87465 (a) (2).
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This requirement was not met as evidenced by staff not following proper eviction procedures for resident which posed a potential health & safety risk to resident 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3