079200752-4-12-2024-15-AS-BFOG-D4LTNG-20240423145243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200752
Report Date: 04/12/2024
Date Signed: 04/12/2024 03:07:16 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
04/02/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240402091607

FACILITY NAME:	FERNBANK PLACE LLC		FACILITY NUMBER:	079200752
ADMINISTRATOR:	IAN SALALILA		FACILITY TYPE:	740
ADDRESS:	5035 FERNBANK WAY		TELEPHONE:	(925) 732-7418
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 6	DATE:	04/12/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Alma Alcantara, Licensee/Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not ensure personnel records are properly maintained

INVESTIGATION FINDINGS:

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On 04/12/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (LC), gathered information and delivered investigation finding of above allegation. LPA explained the purpose of the visit with LC.

During investigation, the department obtained the following documents from LC – Personnel record, Staff fingerprint clearance/associations, staff training/certifications records, job application records, health screening/TB test records.

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: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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-20240402091607

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: FERNBANK PLACE LLC	FACILITY NUMBER: 079200752
	VISIT DATE: 04/12/2024

NARRATIVE

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Allegation: Staff did not ensure personnel records are properly maintained
Investigation Finding: Substantiated
During investigation, LPA observed staff (S1, S2) assisting residents (R1, R2, R3, R4, R5, R6) with activities of daily living (medications, meals, toileting, personal hygiene, bathing, dressing). Staff (S1, S2) confirmed with LPA that they have not completed their fingerprint clearances, 40 hours of job training/shadowing, first aid/CPR certifications prior to working at the facility in late March/early April 2024. Review of Guardian Portal on 04/12/24 showed both staff are not fingerprint cleared and associated to the facility. LPA observed LC instructed staff (S1, S2) to stop working until fingerprint clearances, facility associations and job trainings/first aid/CPR certifications are completed. LC stated current fingerprint cleared/associated and trained staff (LC, S3) will work at the facility until the other staff's (S1, S2) fingerprint clearances/associations and job trainings/certifcations have been completed prior to working at the facility.

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) that staff did not ensure personnel records are properly maintained was found to be substantiated.

Immediate civil penalty of $1,000 assessed during visit for failure to complete fingerprint clearances and facility association requirements for staff (S1, S2).

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: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240402091607

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: FERNBANK PLACE LLC	FACILITY NUMBER: 079200752
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/06/2024 Section Cited CCR 87412(a)(13)	1 2 3 4 5 6 7	For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance	1 2 3 4 5 6 7	By POC due date, LC agreed to submit to CCL completed staff fingerprint clearance, associations, job training and first aid/CPR certifications in compliance with Title 22 regulation Section 87412.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by uncleared and unassociated staff (S1, S2) which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14	Immediate civil penalty of $2,000 assessed for 2 uncleared/unassociated staff (S1,S2) during visit.
	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: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC9099 (FAS) - (06/04)

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