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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011400627
Report Date: 01/24/2025
Date Signed: 01/24/2025 11:24:52 AM

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
09/18/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240918171632
FACILITY NAME:ST. PAUL'S TOWERSFACILITY NUMBER:
011400627
ADMINISTRATOR:YUEN, CONNIEFACILITY TYPE:
741
ADDRESS:100 BAY PLACETELEPHONE:
(510) 835-4700
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:320CENSUS: 198DATE:
01/24/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Cherry Marcelo, Nursing Home Administrator TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility staff financially abused residents in care.

Facility staff did not notify residents' and their authorized representatives of incident.
INVESTIGATION FINDINGS:
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On 01/24/2025 around 09:05 AM, Licensing Program Analysts (LPA) L. Holmes conducted unannounced complaint visit to deliver the findings for the above allegations. LPA met with Cherry Marcelo, Nursing Home Administrator, Staff #1 (S1).

LPAs L. Holmes and D. Doidge conducted the intial 10-day complaint visit on 09/23/24. During the course of the investigation and visit, LPA L. Holmes conducted interviews, requested resident roster, staff roster, police report, APS report, Ombudsman contact information, resident returned checks, facility memos, notifications and documents regarding the alledged actions of Staff #4 (S4) against residents and notification to the Responsible Parties (RP).


Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
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 3
Control Number 15-AS-20240918171632
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: ST. PAUL'S TOWERS
FACILITY NUMBER: 011400627
VISIT DATE: 01/24/2025
NARRATIVE
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...continued from LIC9099.

Facility staff financially abused residents in care.
On 08/16/24, S2 reported to the Oakland Police Department (OPD) that Witness #4 (W4) had a check taken from her apartment and fraudulently written on 08/05/24 and cashed on 08/12/24.

On 08/30/24, S2 reported a second incident to OPD. S1 shared with S2 that Resident #3 (R3’s) check was stole, cashed and written by S4; a third and same incident occurred with R4.

On 09/08/24, W3 emailed Staff (S2, S3, S5, S6) to alert them that he/she had discovered checks were stolen from R1 and had been cashed by W4 per the signatures.

On 09/13/24, S2 reported to OPD that R5 discovered a check had been written against his/her account on 09/05/24. S2 reported to OPD and LPA that S5 was able to identify S4 from the merchant’s camera footage.

A series on fraudulent incidents continued to occur affecting but not limited to R7, R8, R9, R10, R11, R12, & R13. S7 reported that the Executive Director advised him/her to suspend all investigation measures and that Regional Human Resources would be taking over. S3 confirmed that W4 no longer worked at the facility as of 09/24/24.




Facility staff did not notify residents' and their authorized representatives of incident.

After LPA investigated the allegation facility staff financially abused residents in care, interviews with S1, S2 and records reviewed revealed that the ED did not inform all of the St. Paul Tower residents of financial abuse amongst residents until 09/26/24 and LPA confirmed from S1 during the visit that the RPs were informed via an emailed memo on 10/11/2024.

Based on interviews, observations, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.


Exit interview conducted, a copy of this report and appeal rights provided to Cherry Marcelo, S1.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240918171632
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: ST. PAUL'S TOWERS
FACILITY NUMBER: 011400627
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2025
Section Cited
HSC
1569.269(a)(10)
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1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from...financial exploitation...punishment, humiliation, intimidation, and verbal, mental, physical ... - This requirement is not met as evidence by:
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Licensee & ED to assist residents with reconciling financial records and assist residents with securing lost funds via police reports, credit reporting agencies and their banking institutions and conduct in-service training by POC.
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-Based on records reviewed and interviews, the licensee did not comply with the section above once staff financially abused residents which poses/posed a potential health and safety risk to persons in care.
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Type B
02/07/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following. (1) A written report … to the person responsible for the resident within seven days … (D) Any incident which threatens the welfare, safety or health of any resident …-This requirement is not met as evidence by:
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Licensee & ED to ensure that regulatory incidents are reported to all residents and RPs, and that all are aware of the incident of fraudulent abuse & conduct in-service training by POC.

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which threatens the welfare, safety or health …-This requirement is not met as evidence by: Based on records reviewed and interviews, the licensee did not comply with the section above when ED did not report the financial abuse incidents to all residents within seven days which poses/posed a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3