075601547-11-1-2023-15-AS-KHOS-CXBHGF-20231106051105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:29:19 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
07/05/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230705153014

FACILITY NAME:	COUNTRY PLACE ASSISTED LIVING		FACILITY NUMBER:	075601547
ADMINISTRATOR:	RICHARDSON, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1715 OLIVE LANE		TELEPHONE:	(925) 778-5000
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	49	CENSUS: 41	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Shani Edwards, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is unsanitary

INVESTIGATION FINDINGS:

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

On 11/01/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM1) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM1.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, physicians’ orders, showering schedules, housekeeping schedules, incident reports.

Allegation: Facility is unsanitary
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents.
Continued on next page, LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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 8

Control Number 15-AS-20230705153014

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
	VISIT DATE: 11/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility is unsanitary
Investigation Finding: Substantiated
Continuation
Staff (ADM1) confirmed with LPA that the main couch in the living room had urine/feces stains due to frequent usage by residents. LPA observed living room couch had urine stains on fabric during visit on 07/14/23. ADM stated that in August 2023 that she purchased a cleaning machine that staff use regularly to remove the stains and odors from the faux upholstered and suede covered living room couches. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) facility is unsanitary was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 15-AS-20230705153014

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/01/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Deficiency corrected August 2023. Administrator purchased new cleaning machine to remove the stains and odors from the faux and suede upholstered couches in the living room area to ensure the
	8 9 10 11 12 13 14	This requirement was not met as evidenced by unsanitary furniture which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14	furnitures are sanitary in compliance with Title 22 Section 87303 (a).
	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) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
07/05/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230705153014

FACILITY NAME:	COUNTRY PLACE ASSISTED LIVING		FACILITY NUMBER:	075601547
ADMINISTRATOR:	RICHARDSON, JENNIFER		FACILITY TYPE:	740
ADDRESS:	1715 OLIVE LANE		TELEPHONE:	(925) 778-5000
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	49	CENSUS: 41	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Shani Edwards, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is odiferous
Staff do not accord residents with dignity while in care
Staff do not accord residents with privacy while in care
Staff do not ensure that residents have the ability to request assistance when needed
Facility does not have sufficient amount of staff to meet residents’ care needs
Staff do not ensure that residents get a sufficient quantity of food while in care
Staff did not ensure that resident’s diapering needs were met while in care
Staff did not ensure that resident’s showering needs were met while in care

INVESTIGATION FINDINGS:

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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 8

Control Number 15-AS-20230705153014

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
	VISIT DATE: 11/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility is odiferous
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. On 07/14/23 at 10:30AM, LPA toured the facility with staff (S1) including but not limited to the main dining area, kitchen, storage areas, living room, common hallways, bedrooms, bathrooms and activity room. LPA observed no odiferous odors from the areas inspected. LPA also observed S3 cleaning the common hallways while touring with S1. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility is odiferous and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility is odiferous is unsubstantiated.

Allegation: Staff do not accord residents with dignity while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff (S1, S2) who denied not treating residents with dignity while providing care and supervision. Staff (S1, S2) stated they do not tell residents to “go away” or “go sit down” when they need help. During visit. LPA observed staff assisted residents with their prescribed medications, meals without yelling or screaming at them and responded to their requests for help in a friendly manner. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not accord residents with dignity while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not accord residents with dignity while in care is unsubstantiated.

Continued on next page, LIC 9099-C pg2

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 15-AS-20230705153014

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
	VISIT DATE: 11/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff do not accord residents with privacy while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff (ADM1,S2) who stated that most residents know their prescribed medication schedules and would go to the medication room daily to take their prescribed or over the counter medications. S2 stated staff rarely dispense medications in front of other residents in the dining room. LPA interviewed residents (R1, R2, R3, R4) who confirmed they take their daily medications from staff inside the medication room. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not accord residents with privacy while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not accord residents with privacy while in care is unsubstantiated.

Allegation: Staff do not ensure that residents have the ability to request assistance when needed
Investigation Finding: Unsubstantiated
During investigation, LPA toured the facility with staff (ADM1) including but not limited to the main dining, kitchen, living room, bedrooms, bathrooms, activity room. LPA observed each bedroom has an emergency call/pull cord situated against the wall next to the residents’ bed. ADM stated residents can pull the cord when necessary to alert staff for assistance. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not ensure that residents have the ability to request assistance when needed and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure that residents have the ability to request assistance when needed is unsubstantiated.

Continued on next page, LIC 9099-C pg 3

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 15-AS-20230705153014

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
	VISIT DATE: 11/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility does not have sufficient amount of staff to meet residents’ care needs
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed staff records. Review of personnel records dated 07/2023 showed the facility had sufficient staffing including on call staff available for scheduled AM, PM and NOC shifts to provide care and supervision to residents in care. LPA interviewed residents (R1, R2, R3, R4) who stated that staff met their care needs. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility does not have a sufficient amount of staff to meet residents’ care needs and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility does not have a sufficient amount of staff to meet residents’ care needs is unsubstantiated.

Allegation: Staff do not ensure that residents get a sufficient quantity of food while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed scheduled meal deliveries and records. Staff (S1) stated they order and receive deliveries of groceries (variety of meats, breads, fresh fruits, vegetables, cereals, eggs, canned goods, potatoes, pancakes) every week. If residents do not like the food, they are given sandwiches that they can eat plus 2 snacks per day. S1 stated there are a few residents that need to follow a special diet as prescribed by their doctors to control their diabetes, high blood pressure, mechanical soft diet for some with digestive issues. Residents on a regular diet are given second helpings upon request. Staff serve residents breakfast, lunch, dinner, snacks in between meals and drinks daily. LPA observed staff preparing snacks and drinks for residents during visit. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not ensure that residents get a sufficient quantity of food while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure that residents get a sufficient quantity of food while in care is unsubstantiated. Continued on next page, LIC 9099-C pg 4

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 15-AS-20230705153014

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: COUNTRY PLACE ASSISTED LIVING	FACILITY NUMBER: 075601547
	VISIT DATE: 11/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff did not ensure that resident’s diapering needs were met while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. On 07/14/23 at 11:30AM, LPA interviewed resident (R1) who stated that staff helped her with changing her diapers daily. During visit, LPA interviewed other residents (R2, R3, R4) who stated that staff assisted them with their activities of daily living such as showering, toileting, grooming, dressing, changing diapers, medications and meals. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident’s diapering needs were met while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that resident’s diapering needs were met while in care is unsubstantiated.

Allegation: Staff did not ensure that resident’s showering needs were met while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of resident’s (R1) functional assessment dated 07/01/23 showed R1 required total assistance with bathing (helping residentl in and out of the tub, complete washing and drying of the body). During visit, LPA interviewed R1 who stated that staff assists her with bathing, hygiene, toileting, dressing, eating, medications, changing diapers, telephone use and transportation to outings and shopping. LPA observed R1 was clean and odor free. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident’s showering needs were met while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that resident’s showering needs were met while in care is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8