015601466-2-14-2024-15-AS-YFLS-D2WVMH-20240229153333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601466
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:49:40 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
12/05/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20231205083836

FACILITY NAME:	HOUSE OF PSALMS ASSISTED LIVING FOR SENIORS		FACILITY NUMBER:	015601466
ADMINISTRATOR:	CHEN, YANLING		FACILITY TYPE:	740
ADDRESS:	1525 7TH AVENUE		TELEPHONE:	(510) 251-2521
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94606
CAPACITY:	23	CENSUS: 19	DATE:	02/14/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Bamikole Ajibola Ogundele, new owner		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff neglected resident while in care
Staff did not assist resident with medical care

INVESTIGATION FINDINGS:

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On 2/14/24 at 1:15 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver finding in regard to the allegations above. LPA met with Bamikole Ajibola Ogundele, new owner and explained the purpose of the visit.

During the course of the investigation LPA interviewed S1 and reviewed R1’s file. LPA was unable to reach the reporting party. LPA was also unable to interview the alleged victim as he no longer lives at the facility. During a previous visit to this facility (12/13/23) LPA did speak with R1’s family member (W1) who stated that he had no issues with the care R1 received at this facility.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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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Control Number 15-AS-20231205083836

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: HOUSE OF PSALMS ASSISTED LIVING FOR SENIORS	FACILITY NUMBER: 015601466
	VISIT DATE: 02/14/2024

NARRATIVE

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***report continues from LIC9099***

R1 was admitted to the facility on 8/29/23. On 11/30/24 a family member took R1 to a doctor’s appointment due to R1 refusing to eat. R1 was hospitalized after the appointment due to low potassium. W1 states that R1 was discharged from the hospital and transferred to a Skilled Nursing Facility (date unknown). S1 stated the while at the facility R1 received adequate care but was very unhappy with his placement at the facility, often refused to eat and wanted to move. S1 further stated that family members were responsible for taking R1 to his doctors appointments.

This agency has investigated the complaint alleging staff neglected resident while in care and staff did not assist resident with medical care. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC9099 (FAS) - (06/04)

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