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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200751
Report Date: 09/28/2023
Date Signed: 09/28/2023 10:25:48 AM

Substantiated


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
09/19/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230919081749
FACILITY NAME:EAST BAY LONGEVITY ASSISTED LIVINGFACILITY NUMBER:
019200751
ADMINISTRATOR:KAUNG, ALICEFACILITY TYPE:
740
ADDRESS:388 12TH STREETTELEPHONE:
(510) 808-7783
CITY:OAKLANDSTATE: CAZIP CODE:
94607
CAPACITY:49CENSUS: 9DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Wei Xie, Caregiver TIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Staff does not ensure CCL Complaint Poster is posted in entryway of facility.
INVESTIGATION FINDINGS:
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On 9/28/2023 at 9:25 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Caregiver Wei Xie. Administrator Angel Kaung was called and was not able to come to the facility and agreed to have the caregiver sign off on the report.

During the initial 10-day complaint visit LPA observed that the Complaint Poster is not posted in an entryway or common area that is frequented. The poster they they do have is also not 20"x26" in size.

Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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 3
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
09/19/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230919081749

FACILITY NAME:EAST BAY LONGEVITY ASSISTED LIVINGFACILITY NUMBER:
019200751
ADMINISTRATOR:KAUNG, ALICEFACILITY TYPE:
740
ADDRESS:388 12TH STREETTELEPHONE:
(510) 808-7783
CITY:OAKLANDSTATE: CAZIP CODE:
94607
CAPACITY:49CENSUS: 9DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Wei Xie, Caregiver TIME COMPLETED:
10:35 AM
ALLEGATION(S):
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9
Staff did not inform resident's responsible party of incident in a timely manner
INVESTIGATION FINDINGS:
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On 9/28/2023 at 9:25 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Caregiver Wei Xie. Administrator Angel Kaung was called and was not able to come to the facility and agreed to have the caregiver sign off on the report.

During the initial 10-day complaint visit. LPA interviewed two staff, they stated that when a resident has a change in condition or incident they call the families to inform them after they determin if the resident needs medical attention.

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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230919081749
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: EAST BAY LONGEVITY ASSISTED LIVING
FACILITY NUMBER: 019200751
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
87468(c)(2)(A)
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Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475)... The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility.
This requirement is not met as evidence by:
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The facility agrees to post a 20" x 26" in size PUB 475 poster in the entryway. Proof of Correction will be sent to CCLD by POC date.
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The facility not having a 20" x 26" in size poster posted in the entryway
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3