486800782-12-12-2024-21-AS-KMOA-DC4QHA-20241219111046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486800782
Report Date: 12/11/2024
Date Signed: 12/12/2024 09:08:17 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2024 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240807215323

FACILITY NAME:	D HILLSIDE PLACE II		FACILITY NUMBER:	486800782
ADMINISTRATOR:	COPERO, JOHNNY		FACILITY TYPE:	740
ADDRESS:	103 MICHAEL CT.		TELEPHONE:	(707) 552-7584
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 6	DATE:	12/11/2024
		UNANNOUNCED	TIME BEGAN:	01:21 PM
MET WITH:	Johnny Copero, Licensee/Administrator		TIME COMPLETED:	04:22 PM

ALLEGATION(S):

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Insufficient staff to meet residents' needs.
Staff are not meeting resident's toileting needs.
Staff do not serve nutritious meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) A. Canela arrived unannounced to continue complaint investigation regarding the allegations listed above. LPA obtained documents, made observations and took statements.

It was alleged there is Insufficient staff to meet residents' needs, Upon arrival there were 2 staff and 6 residents, of which 2 of the residents R1 and R2 do not require any assistance. Administrator was called and arrived a few minutes later. Residents interviewed did not corroborate allegation and stated the facility staff provide assistance and there is usually 2-3 staff.
It was also alleged staff are not meeting resident's toileting needs. LPA conducted interviews with staff who stated they assist residents and residents are never left in soiled garments. LPA did not get any corroborating statements from residents.

Continue report see LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240807215323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: D HILLSIDE PLACE II	FACILITY NUMBER: 486800782
	VISIT DATE: 12/11/2024

NARRATIVE

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Report continued from LIC9099:

It was also alleged staff do not serve nutritious meals. LPA went over facilities menu plan and took pictures of food items in the refrigerator and freezer.

Food items observed included, vegetables, fruits (blueberries), different milks including oat milk, protein drinks, sausage; deli meats, beef, pork and chicken.
LPA did not get any corroborating statements from residents.

Based on LPAs observations record review and statements received allegations for: Insufficient staff to meet residents' needs, Staff are not meeting resident's toileting needs & staff do not serve nutritious meals; are all UNSUBSTANTIATED at this time. An UNSUBSTANTIATED finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC9099 (FAS) - (06/04)

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