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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201231
Report Date: 04/23/2024
Date Signed: 04/23/2024 01:51:17 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
04/15/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240415154522
FACILITY NAME:DC CARE HOME #2FACILITY NUMBER:
079201231
ADMINISTRATOR:COULTER, DANIEL T.FACILITY TYPE:
735
ADDRESS:4915 TIMBERBROOK WAYTELEPHONE:
(925) 207-7522
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:3CENSUS: 2DATE:
04/23/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Daniel Coulter, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not safeguard residents personal belongings
INVESTIGATION FINDINGS:
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On 04/23/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit and met with staff (ADM, S1). LPA explained the purpose of the visit with staff (S1, ADM), conducted interviews, gathered information and delivered the investigation finding to ADM, S1.

At 12:15 PM, LPA interviewed staff (ADM, S1), gathered and reviewed the following information: Personnel record, Client roster, Client’s (C1) admission agreement, physician’s report, Needs & Services plan, Appraisals, After Visit Summary report, ID/Emergency record, Progress Notes, incident reports.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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 2
Control Number 15-AS-20240415154522
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: DC CARE HOME #2
FACILITY NUMBER: 079201231
VISIT DATE: 04/23/2024
NARRATIVE
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Allegation: Staff did not safeguard resident’s personal belongings
Investigation Finding: Unsubstantiated
During investigation, LPA confirmed with staff (ADM) that client (C1) was first admitted at the facility on 08/05/23. Review of C1's signed Client/Resident personal property and valuables (LIC 621) form dated 08/05/23 and 11/18/23 showed the following personal items declared and signed by C1: 1 cellphone, 6 hoodies, 1 pair of pants, 1 shirt, 1 pair of shoes, 5 pairs of socks, 9 T shirts, 1 PJ, 6 pairs of boxers, 7 pairs of shorts, 1 toothbrush, 1 basketball . ADM stated C1 took most of his personal belongings with him when he left the facility on 12/10/23 and never returned.

ADM stated C1 still left several personal items at the facility for pick-up by C1's responsible party (POA) - a duffle bag filled with clothes/hoodies/jackets, slippers, boots, etc. ADM stated they communicated to POA and RCEB case manager/QA on 12/13/23, 01/29/24, 01/31/24 to arrange pick-up of C1's remaining belongings since C1's POA never responded. ADM stated that on 01/31/24, RCEB case manager picked up C1's 2 big garbage bags full of clothes - underwears, PJ, shorts, shirts and a pair of purple and black Jordan shoes for C1. During visit, LPA observed C1's remaining personal items stored in a duffle bag, two sandals and a pair of boots that still need to be picked up by C1's POA.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not safeguard resident’s personal belongings is unsubstantiated.

Exit interview conducted and a copy of this report provided.

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

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
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