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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601187
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:50:45 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
07/22/2024 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240722141459
FACILITY NAME:HRS CARE HOMEFACILITY NUMBER:
015601187
ADMINISTRATOR:DE LUNA, DIOSDADOFACILITY TYPE:
740
ADDRESS:1352 ASTER LANETELEPHONE:
(925) 454-3320
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 4DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Diosdado De Luna, AdministratorTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Facility does not provide a safe environment for residents, employees, and visitors.
Facility does not provide activity program to address the needs of residents with dementia.
Facility is using a resident's bedroom as passageway to the bathroom.
Facility did not have a sample menu.
INVESTIGATION FINDINGS:
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On 7/29/2024 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Administrator, Diosdado De Luna and informed him reason for the visit.

During the course of investigation, LPA interviewed a resident, 2 staff and complainant. LPA reviewed resident's medical assessments and obtained resident's emergency information.

Facility does not provide a safe environment for residents, employees, and visitors.
LPA observed facility had a broken patio table, patio chairs, hospital bed, and broken vase stored in the walkway space of the backyard area. LPA was informed that the patio table was broken last week.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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 4
Control Number 15-AS-20240722141459
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: HRS CARE HOME
FACILITY NUMBER: 015601187
VISIT DATE: 07/29/2024
NARRATIVE
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Facility does not provide activity program to address the needs of residents with dementia.
Interview with staff revealed there's no activities that address the needs of residents with dementia.

Facility is using a resident's bedroom as passageway to the bathroom.
Interview with staff indicated that both bathrooms are used by everyone. LPA observed facility has a hallway bathroom and a bathroom in R1's room. Interview with resident revealed that R2 have used the bathroom inside R1's room.

Facility did not have a sample menu.
Interview with staff revealed that facility did not have a sample menu for the facility.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20240722141459
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: HRS CARE HOME
FACILITY NUMBER: 015601187
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by:
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Administrator has agreed to remove the broken item and storage items out of the passageway. Administrator will submit picture proof to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by having broken furniture, bed and other items in the passageways of the backyard which poses a potential health and safety risk to the persons in care.
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Type B
08/16/2024
Section Cited
CCR
87705(c)(7)
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Care of Persons with Dementia. An activity program shall address the needs and limitations of residents with dementia... This requirement is not met as evidence by:
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Administrator has agreed to create an activity program to address the needs of each residents with dementia. Administrator will submit the activity program to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having an activity program to address the needs of residents with dementia which poses a potential health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240722141459
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: HRS CARE HOME
FACILITY NUMBER: 015601187
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87307(a)(2)(C)
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Personal Accommodations and Services. No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidence by:
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Administrator has agreed to conduct training to all staff on not using resident's room as passageway to the bathroom and submit staff sign in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by using R1's room as passageway to the bathroom which poses a potential personal rights violation to the persons in care.
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Type B
08/16/2024
Section Cited
CCR
87555(b)(6)
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General Food Service Requirements. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu... This requirement is not met as evidence by:
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Administrator has agreed to create a facility sample menu and submit a copy to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having a sample menu which poses a potential health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4