079200927-3-27-2025-15-AS-KHOS-DFALBT-20250331083717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200927
Report Date: 03/27/2025
Date Signed: 03/27/2025 02:34:54 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
03/21/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20250321142651

FACILITY NAME:	SMG RESIDENTIAL CARE INC		FACILITY NUMBER:	079200927
ADMINISTRATOR:	GONZALEZ, MARIA I		FACILITY TYPE:	740
ADDRESS:	2833 FORTUNA COURT		TELEPHONE:	(925) 209-0791
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 5	DATE:	03/27/2025
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Maria Gonzalez, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not properly report an incident involving the residents
Staff did not prevent the residents from engaging in a physical altercation

INVESTIGATION FINDINGS:

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On 03/27/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information on the allegations and delivered investigation findings. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record (LIC500), residents’ roster, admission agreements, physician's reports, re-appraisals, medical records and incident report.

Continued on next page, LIC9099-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: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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 4

Control Number 15-AS-20250321142651

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: SMG RESIDENTIAL CARE INC	FACILITY NUMBER: 079200927
	VISIT DATE: 03/27/2025

NARRATIVE

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ALLEGATION: Staff did not properly report an incident involving the residents
INVESTIGATION FINDING: Substantiated
During investigation, the department conducted interviews of facility staff (ADM), residents (R1, R2), reporting party (RP) and reviewed R1 & R2 documents.
On 03/24/25 at 10AM, LPA interviewed reporting party (RP) who stated that R1 and R2 had a physical altercation the evening of 02/16/25 and also the next morning before breakfast in their bedroom resulting in R2 sustaining bruising in his right cheek and a cut to his nose.

On 03/27/25 at 1PM, ADM confirmed with LPA that they failed to timely report the incident to Community Care Licensing (CCLD) and Ombudsman (OMB) within the required 48 hours timeline. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not properly report an incident involving residents. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Continued on the 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: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20250321142651

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: SMG RESIDENTIAL CARE INC	FACILITY NUMBER: 079200927
	VISIT DATE: 03/27/2025

NARRATIVE

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ALLEGATION: Staff did not prevent the residents from engaging in a physical altercation
INVESTIGATION FINDING: Substantiated
On 03/24/25 at 10:30AM, LPA interviewed reporting party (RP) who stated that R1 and R2 had a physical altercation on the evening of 02/16/25 resulting in R1 sustaining bruises to his face and a cut to his nose. On 03/27/25 at 1PM, LPA interviewed administrator (ADM) who stated that R1 & R2 had an argument inside their bedroom again in the morning before breakfast. ADM stated R1 punched R2 in the face which bruised his right cheek and cut his nose. On 03/27/25 at 2:35PM, R1 and R2 both confirmed with LPA that no staff redirected them when the incidents occurred inside their bedroom. ADM stated that she did not know about the incident until she noticed R2’s bruised face and cut nose the next morning during breakfast.

ADM stated R2 did not want to go to the hospital to treat his nose and bruises. ADM treated him with cold compress and was offered ibuprofen which he refused. With the residents' consent, ADM moved R2 to another bedroom with another roommate to avoid reoccurrence of the incident. R1 remained in his room without any roommate. On 02/18/25, ADM stated R1 was re-evaluated by his primary care physician and was prescribed increased Olanzapine medication. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not prevent the residents from engaging in a physical altercation. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

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

Exit interview conducted. Appeal Rights 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: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20250321142651

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: SMG RESIDENTIAL CARE INC	FACILITY NUMBER: 079200927
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/18/2025 Section Cited CCR 87211(a)(1)(c)	1 2 3 4 5 6 7	Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).	1 2 3 4 5 6 7	By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on reporting requirements in compliance with Section 87211 (a)(1)(c).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff’s failure to timely report incidents to Community Care Licensing (CCL) and Ombudsman which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14
Type B 04/18/2025 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ personal rights in compliance with Section 87468.2 (a)(4).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff’s failure to redirect aggressive residents which posed a potential health & safety risk to residents in care	8 9 10 11 12 13 14

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: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

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