019200735-12-30-2021-15-AS-KHOS-CAEK2T-20220106063141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200735
Report Date: 12/30/2021
Date Signed: 12/30/2021 05:04:56 PM

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
06/08/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210608160016

FACILITY NAME:	CALIFORNIA MENTOR - MALABAR HOME		FACILITY NUMBER:	019200735
ADMINISTRATOR:	JOSEPH FARRISH III		FACILITY TYPE:	740
ADDRESS:	4639 MALABAR AVE		TELEPHONE:	(909) 483-2505
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	4	CENSUS: 4	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Joseph Farrish III, administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff are overmedicating resident(s)
Staff speak inappropriately to resident(s) in care

INVESTIGATION FINDINGS:

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On 12/30/21 at 5PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Staff are overmedicating residents
Investigation Finding: UNSUBSTANTIATED
During visit on 06/16/21, Licensing Program Analysts (LPAs) A. O’Hollaren and L. Francisco reviewed residents (R1)’s / (R2)’s medications/dosages logs. LPAs observed R1’s/R2’s medications/dosages matched residents’ corresponding medication administration records (MARs). Staff (S1, S4, S5) confirmed with LPAs that they administer residents’ daily medications as prescribed and records them on the MARs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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-20210608160016

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: CALIFORNIA MENTOR - MALABAR HOME	FACILITY NUMBER: 019200735
	VISIT DATE: 12/30/2021

NARRATIVE

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Allegation: Staff speak inappropriately to resident(s) in care
Investigation Finding: UNSUBSTANTIATED
Based on interviews and observations, Licensing Program Analysts (LPAs) A. O’ Hollaren and L. Francisco interviewed staff (S1, S4, S5) on 06/16/21 who denied speaking inappropriately to residents in care. Staff stated they did not hear a staff yell or say “give him his medications so he can be knocked out” while working at the facility.

LPAs tried to interview the four residents who were unable to validate occurrence of these incidents due dementia.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC9099 (FAS) - (06/04)

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