019200737-5-3-2024-15-AS-HHUL-D53P5Q-20240508110107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200737
Report Date: 05/03/2024
Date Signed: 05/03/2024 11:32:29 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
11/16/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20231116135451

FACILITY NAME:	CALIFORNIA MENTOR-MARINEVIEW HOME		FACILITY NUMBER:	019200737
ADMINISTRATOR:	JOSEPH GAPASIN		FACILITY TYPE:	740
ADDRESS:	2420 MARINEVIEW DRIVE		TELEPHONE:	(510) 957-5612
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	4	CENSUS:	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Nena Gibson, Program Supervisor		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not properly report incidents involving a resident
Staff did not seek timely medical attention for the residents
Staff did not address the residents change in medical condition

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 5/3/2024 at 11:05 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Program Supervisor Nena Gibson.

On the allegation facility staff did not properly report incidents involving a resident. Based on record review and interviews the facility the staff did not report the positive skin test because the client has a history of having false positive TB skin tests since the 1980s. The care staff were waiting on reporting it to CCLD until they were able to get the more accurate chest X-ray.

On the allegation facility Staff did not address the residents change in medical condition. Based on record review and interviews the facility was getting the client retested for TB with a different kind of test. They had already made two attempts to get the chest X-ray with no success as the client was not sitting still for the scan.
Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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-20231116135451

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-MARINEVIEW HOME	FACILITY NUMBER: 019200737
	VISIT DATE: 05/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

...Continued from LIC 9099

On the allegation facility staff did not seek timely medical attention for the residents. Based on record review and interviews the facility did schedule medical visits for both R1 and R2 when they got their respiratory infections along with follow up visits when the infections were not clearing up.

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

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2