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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200873
Report Date: 10/31/2024
Date Signed: 10/31/2024 12:10:25 PM

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
02/24/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230224104657
FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:KNOX, KATHLEEN LFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: 54DATE:
10/31/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ebony Foy, Generations Program DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff engaged in a physically inappropriate interaction with resident

Staff made sexually inappropriate comments towards resident

Staff left resident on the floor after a fall for a prolonged period of time
INVESTIGATION FINDINGS:
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On 10/31/2024 at 9:45am, Licensing Program Analysts (LPAs), L. Hall and David Doidge arrived unannounced to deliver complaint findings for the allegations above. LPA met with Ebony Foy, Generations Program Director and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with residents, staff/former staff, witnesses, and obtained and reviewed records, including death report for resident (R2).

Allegation: Staff engaged in a physically inappropriate interaction with resident.

On April 3, 2023, resident (R1) was interviewed at the facility regarding the allegation of being sexually abused by an outside agency staff (S4) in February 2021 while in

Continued on LIC9099.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
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 7
Control Number 15-AS-20230224104657
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: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 10/31/2024
NARRATIVE
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Continued from LIC9099.

care. R1 stated that S4 would come in her room and tell her that he wanted to be her boyfriend and lifted her shirt and kissed her breast. R1 also stated S4 made inappropriate sexual comments referring to her private areas. S4 was employed through an agency called Serving Seniors Care from May 2020 to December 2021. Staff member (S5) revealed that R1 had complained that one of the outside agency staff was inappropriate towards her, but S5 never heard what the inappropriate behavior was.

On April 27, 2023, the Department interviewed W1. W1 stated R1 had told him that one of the male staff members said disgusting things to her and the male staff member also kissed her breasts. An interview with Serving Senior Care staff, (S7), revealed that he/she was aware that S4 was harassing R1 and was aware that S4 had said something sexual to R1. During an interview with suspect, S4, admitted that he told R1 that he wanted to be her boyfriend, asked if he could kiss her, and stated that he made inappropriate sexual comments while he was changing her. S4 said he told R1 those things as a joke and that he knows that it was inappropriate.

Allegation: Staff made sexually inappropriate comments toward a resident.

Interview with R1 on April 3, 2023, revealed that S4 would come into R1’s room and tell R1 that he wanted to be her boyfriend and look at her naked body, which made R1 uncomfortable. S4 also used inappropriate sexual language to refer to R1’s private area. During an interview with S4 on June 15, 2023, S4 admitted to using sexual language and making inappropriate sexual comments towards R1. S4 stated he was joking and admits he was wrong in making those comments.



Continued on LIC9099C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20230224104657
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: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 10/31/2024
NARRATIVE
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Continued on from LIC9099C.

Allegation: Staff left resident on the floor after a fall for a prolonged period of time

Based on an interview with S1 it indicated that R2 was receiving services through an agency called SafelyYou . This service is used to monitor resident unwitnessed falls. S1 stated the system is that if a resident falls, SafelyYou is alerted and immediately contacts the facility and if no one at the facility answers SafelyYou has an additional contact number for the staff at the facility. The staff answering the call from SafelyYou goes to check on the resident. On the day in question, the Department reviewed the time sequence received from the facility regarding R2’s unwitnessed fall and the total time to respond to R2 was 1 hour and 10 minutes. S10 stated she received three (3) calls from SafelyYou to check on R2 and she had notified the person on duty each time a call was received. During the interview with S2, she stated she was working on both floors on the day of the incident, and she did not answer the phone when the agency called because she thought it was a scam call. S2 also stated when S10 told her to check on the resident she then went upstairs to check on her.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20230224104657
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: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2024
Section Cited
CCR
87468.1(a)(3)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This evidence was not met by:
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Generations Program Director agreed to implement a plan on the hiring process from other agencies going forward to CCLD by POC date.
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Based on record review and interviews the Licensee did not comply with the section cited above in keeping resident free from humiliation, which poses a potential health and safety risk to person in care.
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Type A
11/01/2024
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by:
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Generations Program Director agreed to conduct an in-service training for all staff on personal rights and submit documentation to CCLD that the training has been completed by POC date.
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Based on interviews the Licensee did not comply with the section cited above in staff having dignity with residents, which poses a potential health and safety risk to persons in care.
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20230224104657
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: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2024
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary... In facilities licensed for sixteen or more, sufficient support staff shall be employed... Additional staff shall be employed as necessary... The licensing agency may require any facility to provide additional staff... This requirement was not met as evidence by:
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Generations Program Director agreed to review the plan and retrain staff on YouSafely, and submit documentation to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section above in attending to resident needs which poses a potential health and safety risk for persons in care.
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
02/24/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230224104657

FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:KNOX, KATHLEEN LFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: DATE:
10/31/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ebony Foy, Generations Program DirectorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not ensure that medications were centrally stored

Questionable death

Staff did not ensure resident's dietary needs were met
INVESTIGATION FINDINGS:
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On 10/31/2024 at 9:45am, Licensing Program Analysts (LPAs), L. Hall and D. Doidge arrived unannounced to deliver complaint findings for the allegations above. LPA met with Ebony Foy Generations Program Director and explained the reason for the visit.

The Department interviewed the reporting party (RP), residents, a witness, former and present staff, obtained and reviewed records.

Allegation: Staff did not ensure that medications were centrally stored.

The Department interviewed three (3) med techs Staff 5, (S5), Staff 6 (S6), and Staff 8 (S8). All three (3) stated a locked medication cart is used to pass medication to

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20230224104657
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: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 10/31/2024
NARRATIVE
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Continued from LIC9099.

residents. The med techs stated the steps are to push the cart to each room, pour the medication into a cup, pass the cup to the resident, and make sure the resident takes the medication. All three (3) also stated the medication cart is never left unlocked when unattended.
The allegation is Unsubstantiated.

Allegation: Questionable death

During record review the Department reviewed the death report received from the facility on December 21, 2023, that stated R2 had expired, but did not state a cause of death. During the investigation the Department obtained a copy of R2’s death certificate; it stated R2’s cause of death as natural causes.

Allegation: Staff did not ensure resident's dietary needs were met.

The Department interviewed three (3) staff that worked in the kitchen. S13 stated he is given a form from the residents for room service which specifies the residents’ request. If a resident requests diary to be added to their food, it is put on the side not into the food. S14 stated the food that is taken to the residents’ rooms is put on trays and condiments are put on the side for them to add themselves.

Based upon the interviews and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7