079201206-3-26-2025-15-AS-KHOS-DFHNE9-20250407102333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201206
Report Date: 03/26/2025
Date Signed: 03/26/2025 02:04:35 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
11/06/2024 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20241106122340

FACILITY NAME:	GOLDEN AURORA HEALTHCARE CLEARBROOK		FACILITY NUMBER:	079201206
ADMINISTRATOR:	RIVERA, PERSEUS		FACILITY TYPE:	735
ADDRESS:	34 CLEARBROOK ROAD		TELEPHONE:	(925) 499-8464
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 3	DATE:	03/26/2025
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Maria Rivera, Licensee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not properly trained to administer medications.
Staff do not ensure cleaning supplies are not accessible to residents.
Staff serve expired food.
Staff do not ensure residents are provided quality food.
Staff do not ensure resident's mental needs are met.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/26/2025 at 1:35pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Maria Rivera, Licensee and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witness, client, obtained and reviewed records.

Allegation: Staff are not properly trained to administer medications.
W1 stated on initial intake interview that staff do not have training to administer medication. LPA conducted record review for six (6) staff all six have Direct Support Professional (DSP), first-aid, CPR and medication training.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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-20241106122340

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: GOLDEN AURORA HEALTHCARE CLEARBROOK	FACILITY NUMBER: 079201206
	VISIT DATE: 03/26/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099.

Allegation: Staff do not ensure cleaning supplies are not accessible to residents.

W1 stated on initial intake interview staff allow residents access to hazardous chemicals, allow the residents to clean with it, and there are chemicals stored in the resident, C1’s. S2 stated during interview that one of the client’s have an OCD and is able to leave the facility unassisted and buys cleaners and disinfectants, however, when staff observes the cleaners and disinfectants in the client’s room they are removed. S1 also stated the facility does let the client clean while observing.

Allegation: Staff serve expired food.

W1 stated on initial intake interview staff serve expired food to residents. LPA did observe expired food in the refrigerator. S1 stated during interview that C3 goes to the food bank and brings the food into the facility. S2 stated the facility staff is instructed to throw a little of the food away at a time so that C3 will not notice it. S2 stated if staff throws the food away all at once C3 will have a behavior.

Allegation: Staff do not ensure residents are provided quality food.

W1 stated during initial intake interview staff do not serve good quality food and will limit food options to residents. LPA inspected the refrigerator, freezer, and cabinets for food. LPA observed a variety of foods. The food that LPA observed was expired was placed in a special section in the refrigerator and cabinet where staff would be able to identify the foods.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20241106122340

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: GOLDEN AURORA HEALTHCARE CLEARBROOK	FACILITY NUMBER: 079201206
	VISIT DATE: 03/26/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued on LIC9099.

Allegation: Staff do not ensure resident's mental needs are met.

W1 stated during initial intake interview do not provide emotional support to residents. When residents have behavioral issues, the staff show no concern. S2 stated staff try to give personal space when having clients’ behavioral issues. Staff will try to wait until the client calms down to or the medication takes affect to support the client in any way possible. C3 stated during interview that staff helps him when he request help, but sometimes he wants to be left alone.

Based upon observation and the interviews conducted during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3