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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 12/12/2022
Date Signed: 12/12/2022 04:23:36 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
12/05/2022 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20221205100853
FACILITY NAME:CAREFIELD CASTRO VALLEYFACILITY NUMBER:
019200685
ADMINISTRATOR:PARVEEN SINGHFACILITY TYPE:
740
ADDRESS:19960 SANTA MARIA AVETELEPHONE:
(510) 582-2765
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:116CENSUS: 70DATE:
12/12/2022
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Parveen Singh, Senior Excutive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff mismanaged resident's medication
Staff did not complete an initial inventory of resident's personal property
INVESTIGATION FINDINGS:
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2
3
4
5
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7
8
9
10
11
12
13
On 12/12/22 Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation for the above allegation starting at 3:00pm. LPA met with Parveen Singh Senior Executive Director and explained the purpose of the visit.
During visit LPA interviewed Senior Executive Director, and reviewed Former Resident's (R1) admission agreement, physician report, progress notes, and review resident personal property and valuables (LIC 621) agreement.
During the course of the investigation, it was revealed that staff did not mismanaged resident’s medication and is following doctor order when they have confirmation.
During the course of the investigation, it was revealed that resident’s responsible party sign and stated that they are declining to track any personal property of resident.
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 and a copy of this report and appeal rights provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
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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