079200302-4-4-2023-15-AS-CFOR-CQKVUC-20230404164432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200302
Report Date: 04/04/2023
Date Signed: 04/04/2023 04:44:40 PM

Document Has Been Signed on 04/04/2023 04:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	STUART HOUSE, THE		FACILITY NUMBER:	079200302
ADMINISTRATOR:	PAMELA GREEN		FACILITY TYPE:	740
ADDRESS:	3067 BELFAST WAY		TELEPHONE:	(510) 262-0206
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94806
CAPACITY:	6	CENSUS: 4	DATE:	04/04/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	VERONICA WALKER, CAREGIVER/HOUSEKEEPER		TIME COMPLETED:	03:00 PM

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Case management visit for complaint# 15-AS-202209260-82823

On 4/4/2023, at 1:40PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced visit to deliver the findings on the allegation Staff denied resident phone calls and met with Caregiver/Housekeeper Veronica Walker and disclosed the purpose of the visit and was granted entry into the facility. 4 residents and 1 staff were present in the facility during this visit. The facility is a 4-bedroom 2-bath house. Administrator arrived at approximately 2:10PM.

Staff denied resident phone calls: SUBSTANTIATED

RP stated that R1 moved into the facility on August 20, 2022, RP called the facility to speak with R1 and first spoke with S1, RP stated that S1 wanted to know who she was because R1 kept asking for her. RP stated that she spoke with R1 and R1 sounded drugged. RP stated that S1 informed her that R1 could not have any visitors, calls or facetime for 30 days per her house rules during transition period. RP stated that she informed S1 that RP birthday is coming up within a few days and RP would like to see R1.

RP stated that when RP called the facility on 9/27/2022 S1 would not put R1 on the phone until W2 was connected to the call. RP stated that RP called the facility on 9/30/2022 at 3:00pm and 4:19pm there was no answer RP left a message and received a call back from S1 that informed her she needs to call between the hours of 10:00am and 4:00pm and R1 was not at the facility she was at a doctor appointment. RP stated that she made an appointment to visit R1 on 10/01/2022.

CONTINUE ON LIC809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STUART HOUSE, THE	FACILITY NUMBER: 079200302
	VISIT DATE: 04/04/2023

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CONTINUE FROM LIC809

RP stated that RP called on scheduled day to make an appointment to visit, RP called at 12:00pm, 1:00pm and 3:48pm and left a message each time and there was no call back. RP stated that on 12/16/2022 RP called to schedule an appointment to visit and left a message with no call back.

RP stated that on March 10, 2023 RP call local law enforcement (Richmond Police Department) to conduct a welfare check because RP has not been able to reach R1 by phone since March 3, 2023.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted and Plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2023 04:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STUART HOUSE, THE	FACILITY NUMBER: 079200302
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/12/2023 Section Cited	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.	1 2 3 4 5 6 7	Administrator will read and understand regulation. Submit self-certification to CCLD no later than the POC date.
	8 9 10 11 12 13 14	Based on LPA's observation licensee did not comply with the section cited above by restricting R1 phone calls with family which poses a potential health and safety risk to clients.	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) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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