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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601131
Report Date: 09/15/2023
Date Signed: 09/15/2023 04:01:37 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
06/14/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220614120702
FACILITY NAME:DEER VALLEY MANORFACILITY NUMBER:
075601131
ADMINISTRATOR:DAYTON, GLICERIA C.FACILITY TYPE:
740
ADDRESS:5041 MOCCASIN WAYTELEPHONE:
(925) 757-4152
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
03:29 PM
MET WITH:Gliceria Dayton, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff opens resident’s mail
INVESTIGATION FINDINGS:
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On 09/15/23 at 3:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator (ADM) and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

Allegation: Staff opens resident’s mail
Investigation Finding: Substantiated
During investigation, staff (ADM) confirmed with LPA that she opens and cuts resident (R1) mail in front of her. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff opens resident’s mail was found to be substantiated. Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
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 6
Control Number 15-AS-20220614120702
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: DEER VALLEY MANOR
FACILITY NUMBER: 075601131
VISIT DATE: 09/15/2023
NARRATIVE
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Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20220614120702
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: DEER VALLEY MANOR
FACILITY NUMBER: 075601131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87468.1(a)(15)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights (15) To send and receive unopened correspondence in a prompt manner…
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By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on residents’ personal rights in compliance with Title 22 Section 8748.1 regulations.
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This requirement was not met as evidenced by staff opens resident’s mail which posed a potential health & safety risk to resident 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/14/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220614120702

FACILITY NAME:DEER VALLEY MANORFACILITY NUMBER:
075601131
ADMINISTRATOR:DAYTON, GLICERIA C.FACILITY TYPE:
740
ADDRESS:5041 MOCCASIN WAYTELEPHONE:
(925) 757-4152
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 5DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
03:29 PM
MET WITH:Gliceria Dayton, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff infringes on resident’s privacy
Staff yells at resident
Staff overcharge resident on transportation and incontinent supplies
Staff is not trained/certified to care for Alzheimer’s & Dementia residents
Financial abuse
Staff limits private visitation hours and social activity
INVESTIGATION FINDINGS:
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On 09/15/23 at 3:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator (ADM) and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

Allegation: Staff infringes on resident’s privacy
Investigation Finding: Unsubstantiated
During investigation, staff (ADM) denied infringing on resident’s (R1) privacy. LPA interviewed residents (R1, R3, R4) who confirmed that staff respect their privacy whenever they have visitors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff infringes on resident’s privacy is unsubstantiated.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20220614120702
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: DEER VALLEY MANOR
FACILITY NUMBER: 075601131
VISIT DATE: 09/15/2023
NARRATIVE
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Allegation: Staff yells at resident
Investigation Finding: Unsubstantiated
During investigation, Staff (ADM) denied yelling or hitting any resident at the facility. Residents (R1, R3, R4) confirmed with LPA that staff do not yell or scream at them. Residents state that staff treat them well and have no concerns residing at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff yells at resident is unsubstantiated.

Allegation: Staff overcharge resident on transportation and incontinent supplies


Investigation Finding: Unsubstantiated
During investigation, administrator (ADM) stated that responsible party (RP) arranges for residents (R1, R2) transportation to medical appointments and pays the driver directly. Review of R1 and R2’s admission agreements dated 10/27/21 show RP provides for transportation of residents to medical and dental appointments. LPA also reviewed signed admission agreements dated 10/27/21 which states that supplies required for incontinence shall be provided by the responsible person and will not be supplied by the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff overcharge residents on transportation and incontinent supplies is unsubstantiated.

Allegation: Staff is not trained/certified to care for Alzheimer’s & Dementia residents


Investigation Finding: Unsubstantiated
During investigation, administrator (ADM) confirmed with LPA that staff has completed 10 hours of Dementia/Alzheimer training. LPA reviewed staff (S1, S2, S3, S4, S5) training certifications on Dementia/Alzheimer dated 06/20/22. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff is not trained/certified to care for Alzheimer/Dementia residents is unsubstantiated.

Continued on next page, LIC 9099-C pg2

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20220614120702
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: DEER VALLEY MANOR
FACILITY NUMBER: 075601131
VISIT DATE: 09/15/2023
NARRATIVE
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Allegation: Financial abuse
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed residents (R1, R3, R4) who state that staff do not financially abuse them. They pay their monthly dues based on the agreed upon admission agreements/addendums. LPA reviewed residents (R1, R2) admission agreements signed by responsible party (RP) dated 10/27/21, higher level of care monthly rate increase signed by RP dated 04/13/22 and notice of monthly charges increase signed by RP dated 06/01/23. LPA observed a comprehensive written description of the rate increase and payment procedures on all documents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff financially abuse residents is unsubstantiated.

Allegation: Staff limits private visitation hours and social activity


Investigation Finding: Unsubstantiated
During investigation, administrator (ADM) denied limiting visitation hours and social activity for residents. ADM stated visitors are screened for COVID symptoms by staff to ensure they follow the infection control public health requirements and not compromise the health and safety of residents and staff. LPA interviewed residents (R1, R3, R4) who confirmed that family and friends visit them at the facility with no restrictions from staff on visitation hours and social activity. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff limits private visitation hours and social activity is unsubstantiated.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6