071440693-8-20-2024-15-AS-KHOS-D8RKL7-20240903075928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 071440693
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:04:42 PM

Unsubstantiated

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
10/22/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211022153936

FACILITY NAME:	PARK PLAZA REST HOME		FACILITY NUMBER:	071440693
ADMINISTRATOR:	JOSEPH, JANICE		FACILITY TYPE:	740
ADDRESS:	4901 PLAZA WAY		TELEPHONE:	(510) 233-3240
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	6	CENSUS: 3	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Janice Joseph/Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Uncleared adult is providing care and supervision to residents.

INVESTIGATION FINDINGS:

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On this day, August 20, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegation. LPA met with Janice Joseph, administrator, and informed the reason for visit.

It was alleged that the administrator leaves the facility from Friday evening to Sunday night and sometimes Monday morning with uncleared person in the facility providing assistance to residents. If was further alleged that this person whom licensee was cited for this person for working in the facility without fingerprint clearance.

On 10/26/21, LPA reviewed residents’ record and conducted interviews. LPA interviewed 4 residents and staff (S2 and administrator). LPA obtained copy of LIC500 Personnel Report which showed S1 was not on the schedule.
..continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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 15-AS-20211022153936

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: PARK PLAZA REST HOME	FACILITY NUMBER: 071440693
	VISIT DATE: 08/20/2024

NARRATIVE

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Two (2) of the residents interviewed were not able to provide the names of the caregivers while 1 of residents at first stated did not know the name of the caregivers then stated knew S1 but does not remember the dates and days S1 worked. The other resident stated S1 worked but this resident was not able to provide clear information when further asked.

Review of records showed the facility was cited for a complaint for S1 who was not fingerprinted and cleared, and deficiency was cleared. The staff and administrator stated S1 worked before but no longer worked since S1 had a problem with fingerprint clearance.

Based on all information gathered, there is not a preponderance of evidence to prove that the alleged violation occur, therefore the allegation is closed as unsubstantiated.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

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