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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200999
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:24:20 PM

Unfounded


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
09/06/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230906151037
FACILITY NAME:WARM HOUSEFACILITY NUMBER:
019200999
ADMINISTRATOR:DELGADO, CLARAFACILITY TYPE:
740
ADDRESS:7693 DONOHUE DR.TELEPHONE:
(925) 323-8958
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:6CENSUS: 4DATE:
09/11/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Steve Chou, Facility MangerTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Resident sustained injury while in care
INVESTIGATION FINDINGS:
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On 9/07/2022 at 10AM Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct initial 10-day complaint investigation for the above allegations. LPA met with Steve Chou, facility manager and explained the purpose of the visit.

It was alleged that resident sustained injury while in care. LPA reviewed R1 file; past to present incident reports, hospice nursing progress note, and visitation log. LPA interviewed S1, S2, and RP. LPA spoke with RP on 9/11/23 at 9:47AM. RP stated that RP follow up with the hospital nurse regrading R1 left leg decoration. Hospital nurse confirmed that R1 did not sustained any bone fractures, nor any injury. The cause of the leg discoloration is cause by vein issue and led to circulator issue. S1, and S2 stated R1 did not have or had any injury while R1 resided at the facility.Therefore, the allegation is Unfounded.

Report continue on LIC 9099C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
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 2
Control Number 15-AS-20230906151037
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: WARM HOUSE
FACILITY NUMBER: 019200999
VISIT DATE: 09/11/2023
NARRATIVE
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Per records review and interviews, the Department has investigated this complaint and has determined it to be Unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2