275294182-10-21-2021-26-AS-KHOS-C8KLGU-20211108074519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275294182
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:49:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20201229134852

FACILITY NAME:	DRAKE HOUSE		FACILITY NUMBER:	275294182
ADMINISTRATOR:	JULIE HUYNH		FACILITY TYPE:	740
ADDRESS:	399 DRAKE AVENUE		TELEPHONE:	(831) 643-9069
CITY:	MONTEREY	STATE: CA	ZIP CODE:	93940
CAPACITY:	55	CENSUS: 50	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Jenny Lombarte		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident's room has an odor
Staff did not treat resident appropriately

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Jenny Lombarte Assistant Administrator.

The Department received notice of the above complaint allegations on 12/29/2020.

On 1/8/2021 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit to open the 10 Day Complaint investigation.

On 6/24/2021 LPA conducted an on site complaint visit and toured the facility.

Between 1/8/2021 and 10/21/2021 5 staff and 11 residents were interviewed.
Records reviewed included residents’ records, Admission Agreement, Progress Notes and Privacy Polices.

Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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 5

Control Number 26-AS-20201229134852

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: DRAKE HOUSE	FACILITY NUMBER: 275294182
	VISIT DATE: 10/21/2021

NARRATIVE

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Also, LPA reviewed Deep Cleaning Schedule for 12/30/2020 through 1/1/2021 and Laundry Schedules for 12/30/2020 through 1/30/2021.

4 of 4 staff (S1-S4) are unaware of any odor issues in R1’s room. 10 of 10 residents interviewed stated the facility is clean and sanitary. These residents were unaware of any odor issues in R1’s room. Deep Cleaning Scheduled notes R1’s room was deep cleaned on 12/14/2020. S4 Housekeeping staff stated that the residents’ rooms are cleaned daily and laundry service is done on a daily basis or as needed.

3 of 4 staff stated that they were unaware of anytime staff spoke to or treated a resident disrespectfully. 4 staff member does not get involved with direct care of residents.

10 of 10 residents did not see or hear staff treat a resident inappropriately.

The Department has investigated the above complaint allegations. Based on information from interviews conducted , observations and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20201229134852

FACILITY NAME:	DRAKE HOUSE		FACILITY NUMBER:	275294182
ADMINISTRATOR:	JULIE HUYNH		FACILITY TYPE:	740
ADDRESS:	399 DRAKE AVENUE		TELEPHONE:	(831) 643-9069
CITY:	MONTEREY	STATE: CA	ZIP CODE:	93940
CAPACITY:	55	CENSUS: 50	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Jenny Lombarte		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not safeguard resident's property
Resident not provided privacy

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Jenny Lombarte Assistant Administrator.

The Department received notice of the above complaint allegations on 12/29/2020.

On 1/8/2021 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit to open the 10 Day Complaint investigation.

On 6/24/2021 LPA conducted an on site complaint visit and toured the facility.

Between 1/8/2021 and 6/24/2021 4 staff and 10 residents were interviewed.

Page 1 of 3

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20201229134852

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: DRAKE HOUSE	FACILITY NUMBER: 275294182
	VISIT DATE: 10/21/2021

NARRATIVE

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Records reviewed included residents’ records, Admission Agreement, Progress Notes, Theft Loss and Prevention Program and Privacy Polices. Also, LPA reviewed Laundry Schedules for 12/30/2020 through 1/30/2021.

4 of 4 staff were unaware of any lost or missing laundry. S2 stated that they ask residents to update their personal inventory list but sometimes residents do not. All clothing items are initialed by staff to identify the resident’s clothing to prevent items getting mixed up or lost. S1 stated that sometimes clothing items get mixed up during laundry service and staff will look for the items to return to the owner.

Progress Notes dated 1/13/21 indicate that R1 reported to staff that 2 missing clothing items were found. R1 did not have these items initialed before giving them to housekeeping for washing.

Theft and Loss Prevention Program states: "The facility shall not be liable for items , which have not been inventoried"

10 of 10 residents did not have any issues or concerns with laundry service or their personal property.

2 of 4 staff were unaware of any privacy issues and stated that office space is made available to residents for their use to speak privately with others. The other 2 Staff members do not provide direct care services.

Admission Agreement States under Item 17. PRIVACY states “Sleeping and bathroom/bathing areas are private. Staff and residents must knock on closed bedroom or bathroom doors, wait a minute, call out before entering".

10 of 10 residents did not have any concerns or issues regarding privacy. Privacy is provided when requested.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20201229134852

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: DRAKE HOUSE	FACILITY NUMBER: 275294182
	VISIT DATE: 10/21/2021

NARRATIVE

1
2
3
4
5
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7
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12
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32

On 6/24/2021 and 10/21/2021 during site tours, office space was observed for residents' use if requested.

This Department has investigated the complaint allegations listed. Based on interviews, observations, review of records, the Department has found that the complaint allegations are UNFOUNDED, meaning that the allegations are false, could not have happened and/or is without a reasonable basis.

Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided.

Page 3 of 3

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5