079201226-4-9-2026-15-AS-LFRO-DVVKEP-20260711075041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201226
Report Date: 04/09/2026
Date Signed: 04/09/2026 12:07:44 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
04/06/2026 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20260406085737

FACILITY NAME:	ST LOUIS CARE HOME		FACILITY NUMBER:	079201226
ADMINISTRATOR:	COLLADO, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	921 ST LOUIS CT		TELEPHONE:	(925) 954-7777
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 5	DATE:	04/09/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nisel Mamucud, Nisel Mamucud		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide medical attention to resident in a timely manner
Facility did not report an incident(s) to parent/authorized representative

INVESTIGATION FINDINGS:

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

On 04/09/2026 at 10:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with staff Nisel Mamucud. Administrator Charmaine Collado was called and informed of the visit.

During the initial 10-day complaint visit, LPA interviewed staff, collected the following documents: Resident 1's (R1) physicians report, R1's incident report, R1's emergency contact information sheet.

On the allegation: Staff did not provide medical attention to resident in a timely manner
Based on interviews Staff did not call 9-11 after R1 fell and hit their head on the floor. S2 stated that W1 was called after the incident happened and said not to take R1 to the hospital. W1 came the next day and took R1 to the hospital then.

Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

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-20260406085737

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: ST LOUIS CARE HOME	FACILITY NUMBER: 079201226
	VISIT DATE: 04/09/2026

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 LIC 9099

On the allegation: Facility did not report an incident(s) to parent/authorized representative
Based on interviews and records review, the facility did not report the incident of R1 falling and hitting their head on the floor to the residents responsible party. S1 stated that W1 was called and informed but documents do not list W1 as R1's responsible party.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20260406085737

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: ST LOUIS CARE HOME	FACILITY NUMBER: 079201226
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/23/2026 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified... event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agrees to review the regulation and submit a letter of self certification to CCLD by POC date
	8 9 10 11 12 13 14	The facility not reporting to Licensing or the responsible party that the resident fell and hit his head.	8 9 10 11 12 13 14
Type B 04/23/2026 Section Cited CCR 87645(a)(1)	1 2 3 4 5 6 7	(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).	1 2 3 4 5 6 7	Administrator to in-service the staff and submit copy of training topics with attendees signatures by 4/23/26.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by resident sustaining a fall and hitting their head while in care and staff did not call 9-1-1.	8 9 10 11 12 13 14

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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3