011440776-6-11-2024-15-AS-KHOS-D6BNKK-20240617103205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011440776
Report Date: 06/11/2024
Date Signed: 06/11/2024 04:11:10 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
06/11/2024 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240611093843

FACILITY NAME:	BAYWOOD COURT		FACILITY NUMBER:	011440776
ADMINISTRATOR:	MANJOT KAUR		FACILITY TYPE:	740
ADDRESS:	21966 DOLORES STREET		TELEPHONE:	(510) 733-2422
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	72	CENSUS: 50	DATE:	06/11/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Manjot Kaur		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff handled inappropriately resulting in fracture.

INVESTIGATION FINDINGS:

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On 6/11/2024 at 02;45 PM, Licensing Program Analysts (LPAs) James Sampair and Ardalan Gharachorloo arrived unannounced to conduct the initial 10-day complaint inspection of the facility pertaining to the allegation above. Upon arrival, LPAs stated the purpose of the visit to Administrator (ADM) Manjot Kaur.

The complainant alleged that the resident (R1) was handled inappropriately resulting in a fracture.
LPAs met with ADM, who stated that R1 is a resident in skilled nursing and has never been a resident in assisted living.

The allegation is false, could not have happened, and/or is without a reasonable basis, therefore, the allegation is UNFOUNDED.

Exit interview conducted and a copy of this report provided for ADM.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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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