079201196-5-8-2023-15-AS-HHUL-CRYTEF-20230519143951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201196
Report Date: 05/08/2023
Date Signed: 05/08/2023 05:21:09 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
02/15/2023 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20230215105338

FACILITY NAME:	COGIR OF BRENTWOOD		FACILITY NUMBER:	079201196
ADMINISTRATOR:	HARRISON, DAMIKA		FACILITY TYPE:	740
ADDRESS:	150 CORTONA WAY		TELEPHONE:	(925) 240-0733
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	150	CENSUS: 87	DATE:	05/08/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Jeff Freeth, Executive director		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Facility did not administer medication to resident as ordered by the doctor
Facility charged the resident for services not being provided
Insufficient staffing

INVESTIGATION FINDINGS:

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On 5/8/2023 at around 2:15PM, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct an unannounced complaint visit and deliver the investigation finding. LPA explained the purpose of the visit with new Administrator Jeff Freeth and facility nurse Kuldip Singh.

Allegation: Facility did not administer medication to resident as ordered by the doctor

Based on records review, medication administration records (MAR) revealed that staff provided R1’s medication according to physician’s order. R1’s MAR revealed there was no miss medications and discontinued medication was stopped per doctor’s order. LPA attempted to interview R1 regarding this allegation however R1 no longer live at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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-20230215105338

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: COGIR OF BRENTWOOD	FACILITY NUMBER: 079201196
	VISIT DATE: 05/08/2023

NARRATIVE

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Allegation: Facility charged the resident for services not being provided

During the course of investigation, based on residents’ interview, they denied being charged of the services that was not being provided. R4, R5, R6 and R7, stated they do not have billing issues now and staff are assisting them if they needed help or assistance. Based on staff interview, when resident (R1) was admitted on hospice, the facility created a new care plan. Records review revealed that new care plan for resident (R1) was signed by staff and resident’s responsible party before it was implemented.

Allegation: Insufficient staffing

LPA reviewed staff schedule for the facility, facility has Med Tech, support staff and other agency staffing available on schedule. Facility had sufficient staffing for all three (3) shifts. Residents were observed calm and comfortable in their surroundings. LPA conducted interview with residents and residents reported that they are happy living at the facility and had no issues around staff availability to meet their needs. Based on residents’ interview, residents reported that facility staff attend to their needs.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC9099 (FAS) - (06/04)

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