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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601283
Report Date: 04/25/2024
Date Signed: 04/25/2024 06:23:50 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
04/24/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230424094739
FACILITY NAME:PARKVIEW, THEFACILITY NUMBER:
015601283
ADMINISTRATOR:ZAININGER, SYLVIAFACILITY TYPE:
740
ADDRESS:100 VALLEY AVETELEPHONE:
(925) 461-3042
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:123CENSUS: 96DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Aireen Tibon, Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff failed order refills in a timely manner
INVESTIGATION FINDINGS:
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On 4/25/2024 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Associate Executive Director, Aireen Tibon.

During the course of investigation, LPA interviewed 2 staff and complainant. LPA reviewed and obtained staff roster with contact information, physician notification forms, physician's report, medication list, MAR, care notes, and correspondences.

Interview with staff indicated that facility would submit fax request to the doctor for medication refills. S1 stated that R3 did not have insurance for a period of time in March of 2023. After reviewing the MAR and care notes, LPA observed that R3 was not given one medication starting 3/1/2023 due to not obtaining refill. However, facility did not contact responsible party until 3/22/2023 for assistance with medication refills. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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-20230424094739
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: PARKVIEW, THE
FACILITY NUMBER: 015601283
VISIT DATE: 04/25/2024
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20230424094739
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: PARKVIEW, THE
FACILITY NUMBER: 015601283
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by:
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Executive Director has agreed to create a new procedure for medication refills and conduct training for staff. ED will submit new procedure and staff sign in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not obtaining medication refills in a timely manner which poses a potential health and safety risk to the 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
04/24/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230424094739

FACILITY NAME:PARKVIEW, THEFACILITY NUMBER:
015601283
ADMINISTRATOR:ZAININGER, SYLVIAFACILITY TYPE:
740
ADDRESS:100 VALLEY AVETELEPHONE:
(925) 461-3042
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:123CENSUS: 96DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Aireen Tibon, Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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2
3
4
5
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7
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9
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12
13
On 4/25/2024 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Associate Executive Director, Aireen Tibon.

During the course of investigation, LPA interviewed 2 staff and complainant. LPA reviewed and obtained staff roster with contact information, physician notification forms, physician's report, medication list, MAR, care notes, and correspondences. Information obtained regarding staff mismanaged resident's medication was based on medication refills were not ordered in a timely manner. The allegation regarding "Staff failed order refills in a timely manner" was addressed in a separate report.

This agency has investigated the complaint allegation. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4