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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200670
Report Date: 05/13/2024
Date Signed: 05/17/2024 07:37:08 AM

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
01/09/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230109152150
FACILITY NAME:ACAPULCO SENIOR CARE HOMEFACILITY NUMBER:
019200670
ADMINISTRATOR:KA, NINFACILITY TYPE:
740
ADDRESS:14160 ACAPULCO ROADTELEPHONE:
(510) 924-7457
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:0CENSUS: 0DATE:
05/13/2024
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Joyce Galera-Rodriguez, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Lack of supervision
Resident sustained a fall while in care
Resident left unassisted
Insufficient staffing
INVESTIGATION FINDINGS:
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On 5/13/2024 at 4:30PM, Licensing Program Analyst (LPA) G. Luk spoke with Administrator, Joyce Galera-Rodriguez to deliver complaint findings for the allegations above.

During the investigation, LPA interviewed 2 residents, 2 staff, and complainant. LPA reviewed and obtained documents including staff schedule, physician's report, emergency information, and discharge records.

Lack of supervision:
Interview with residents revealed there's always staff present at the facility and can call staff for assistance. Interview with staff indicated there's a live in caregiver and residents sleeps at night. According to R1's physician's report, R1 does not have a history of wandering behaviors.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
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-20230109152150
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: ACAPULCO SENIOR CARE HOME
FACILITY NUMBER: 019200670
VISIT DATE: 05/13/2024
NARRATIVE
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Resident sustained a fall while in care:
Interview with complainant revealed there was an incident where R1 was found outside of the facility near the driveway and might have fallen down. Interview with staff indicated R1 left the facility and neighbors called 911. S2 stated R1 had no falls.

Resident left unassisted:
Interview with residents revealed that staff is available to help residents when needed. R2 stated he had a fall a couple weeks ago and staff provided assistance.

Insufficient staffing:
Interview with residents revealed there's enough staff to assist the two residents at the facility.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegations are UNSUBSTANTIATED.

No deficiencies are being cited on this date.

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

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2