075601490-7-31-2023-15-AS-KHOS-CXBK2X-20231106063153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601490
Report Date: 07/18/2023
Date Signed: 07/31/2023 11:53:44 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
07/13/2023 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230713104549

FACILITY NAME:	MAUREEN HOUSE		FACILITY NUMBER:	075601490
ADMINISTRATOR:	JOSE MICHAEL TORIO		FACILITY TYPE:	740
ADDRESS:	590 MAUREEN LANE		TELEPHONE:	(925) 818-6536
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Albert Bernardino		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Licensee does not provide activities for residents in care.

INVESTIGATION FINDINGS:

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This is an amended report.

On 07/18/2023, at 9:30am, Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPAs met with Albert Bernardino and explained the reason for the visit.

Allegation: Licensee does not provide activities for residents in care.

LPAs reviewed a copy of the facility's June 2023 Calendar that only included activities, i.e., Bingo, Arts and Crafts alternating on Thursdays only.

***continuation on Lic 9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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 5

Control Number 15-AS-20230713104549

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAUREEN HOUSE	FACILITY NUMBER: 075601490
	VISIT DATE: 07/18/2023

NARRATIVE

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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted with Administrator. Appeal rights and copy of this report was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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
E BAY DELTA AC/SC, 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
07/13/2023 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230713104549

FACILITY NAME:	MAUREEN HOUSE		FACILITY NUMBER:	075601490
ADMINISTRATOR:	JOSE MICHAEL TORIO		FACILITY TYPE:	740
ADDRESS:	590 MAUREEN LANE		TELEPHONE:	(925) 818-6536
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Albert Bernardino		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not maintain a comfortable temperature for resident.
Staff do not ensure requirements for the use of oxygen equipment are met.
Licensee does not ensure staff administering oxygen to residents are appropriately trained.
Resident sustained unexplained bruises while in care.

INVESTIGATION FINDINGS:

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On 07/18/2023, at 9:30am, Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPAs met with Albert Bernardino and explained the reason for the visit.

Allegations:
Staff do not maintain a comfortable temperature for resident.
Based on observation, facility's thermostat is set at 73 degrees Fahrenheit. Administrator states the facility has a centralized air-conditioning system and that each room has extra fan. Per research with Weather.gov, the temperature in Pleasant Hill, CA the highest was 90 degrees Fahrenheit on 7/12/2023. Title 22 Regulations says that temperatures should range between 78-85 degrees Fahrenheit.

***continuation on Lic 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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 15-AS-20230713104549

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAUREEN HOUSE	FACILITY NUMBER: 075601490
	VISIT DATE: 07/18/2023

NARRATIVE

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Staff do not ensure requirements for the use of oxygen equipment are met.
Based on observation, the facility has 1 large oxygen tank and 23 small oxygen tanks located in the garage. R1 has an oxygen concentrator and an oxygen tank set-up on a rack in the bedroom.

Licensee does not ensure staff administering oxygen to residents are appropriately trained.
Based on interview with Administrator and record review, R1 is able to turn their oxygen on/off with cueing. The staff can assist R1 with placing the nasal cannula. Administrator provided certificate of training documents of Oxygen Operations - Electric to Portable Use for 5 staff caregivers.

Resident sustained unexplained bruises while in care.
Based on record review, R1 is on Xarelto medication which is a blood thinner.
Taking a blood thinner can cause bruising as a side effect. S1, S2 and S3 state R1 is able to assist with transfers. Staff denied holding R1's arms when transferring.

Based on LPAs observations, interviews and record reviews which were conducted, the above allegations are unsubstantiated.

Although the allegations 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.

Exit interview conducted. Appeal rights and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20230713104549

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAUREEN HOUSE	FACILITY NUMBER: 075601490
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/25/2023 Section Cited CCR 87219(a)	1 2 3 4 5 6 7	87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.	1 2 3 4 5 6 7	Administrator will submit a completed copy of scheduled activity calendar from July thru December 2023 to CCL.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by not having a planned calendar of activities for residents which poses as a potential risk to the health and safety of clients under care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5