079200827-3-6-2025-15-AS-KHOS-DEPN8G-20250312101419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200827
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:01:20 PM

Unsubstantiated

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
08/07/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230807122525

FACILITY NAME:	LOVING HANDS CARE HOME LLC		FACILITY NUMBER:	079200827
ADMINISTRATOR:	SAN DIEGO-TOMAS, CECILIA		FACILITY TYPE:	740
ADDRESS:	748 VAQUEROS AVE		TELEPHONE:	(510) 245-3738
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY:	6	CENSUS: 3	DATE:	03/06/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Edelyn Tupas, Care Giver		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff do not administer resident's medication as prescribed.
Staff do not ensure that resident(s) are provided food that is of quality and in the quantity necessary to meet the needs of the resident(s).
Staff are not providing documentation regarding resident to their Responsible Party as necessary.

INVESTIGATION FINDINGS:

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On 3/6/2025 at 10:00am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced deliver finding for the complaint investigation in regard to the allegation above. LPA K. Nguyen was greeted by the door by Edelyn Tupasp, caretaker. LPA K. Nguyen spoke with Cecelia San Diego-Tomas, Administrator (ADM) over the phone, and explained the purpose of the visit. ADM was not available to come to the facility and gave permission to Edelyn to sign the report.

Allegation: Staff do not administer resident's medication as prescribed- Unsubstantiated
During the course of investigation, LPA interviewed 3 staff and 5 residents. LPA observed 1 resident in the living room and 2 residents in their bedroom. LPA received and reviewed the following documents: communication logs between RP and S1, MAR for 5 residents, staff roster with contact numbers, physician's report, care plan, MAR, emergency information, facility progress notes for R1, R2, and R3.

Report continue on LIC 9099c…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

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-20230807122525

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: LOVING HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
	VISIT DATE: 03/06/2025

NARRATIVE

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RP stated that R1 was not given medication as prescribed. Based on interviews and information obtained from the MAR (medication administration record) shows that R1 received medications as prescribed, the MAR is signed by staff at the time medication is given.

Allegation: Staff do not ensure that resident(s) are provided food that is of quality and in the quantity necessary to meet the needs of the resident(s) – Unsubstantiated

During the course of investigation, LPA interviewed 3 staff and 5 residents. LPA observed residents are having lunch. LPA interviewed 5 residents, 5 out of 5 stated that they have no complaints on the quality of their food. LPA reviewed 5 residents files and 5 out of 5 do not have any restricted diet on files.

Allegation: Staff are not providing documentation regarding resident to their Responsible Party as necessary – Unsubstantiated

During the course of investigation, LPA interviewed 3 staff, 3 out of 3 stated RP have not request any documents from them. S1 stated “I communicate with RP almost daily and have not received any files requested from RP via text, mail, or verbal.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conduct and a copy of report provided to Administrator.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC9099 (FAS) - (06/04)

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