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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:28:43 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
10/01/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211001153104
FACILITY NAME:CAREFIELD CASTRO VALLEYFACILITY NUMBER:
019200685
ADMINISTRATOR:PARVEEN SINGHFACILITY TYPE:
740
ADDRESS:19960 SANTA MARIA AVETELEPHONE:
(510) 582-2765
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:116CENSUS: 45DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Katherine 'Kathy' Maningding/Assisted
Living Director		TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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-Staff did not manage resident's O2 tank properly.

-Staff failed to keep the facility clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct investigation of the above allegations. LPA met with Assisted Living Director (ALD) Katherine 'Kathy' Maningding and informed the purpose of visit.

LPA conducted inspection with Maningding and obtained copies of resident roster. LPA selected 4 resident's rooms for inspection. LPA observed soiled carpet flooring on 3 out of the 4 rooms inspected. LPA also observed 2 of the 4 residents use oxygen (O2) and LPA observed 3 O2 tanks blocking the sliding door in 1 of the resident's room. LPA further observed 4 O2 tanks all over one of the other resident's room with no "No Smoking. Oxygen in Use" sign in the door of this room. LPA further observed no O2 signage at facility's entrance door.


....continued next page (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 6
Control Number 15-AS-20211001153104
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: CAREFIELD CASTRO VALLEY
FACILITY NUMBER: 019200685
VISIT DATE: 10/06/2021
NARRATIVE
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Based on information obtained and observation, the preponderance standard has been met, therefore the allegations of "Staff did not manage resident's O2 tank properly" and "Staff failed to keep the facility clean." are substantiated.

Deficiencies and plan and proof of corrections were discussed with K. Maningding.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20211001153104
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: CAREFIELD CASTRO VALLEY
FACILITY NUMBER: 019200685
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

-This requirement is not met as evidenced by:
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ALD to checked all residents' rooms and have all the flooring cleaned as needed. Proof/pictures to be sent by 10/20/2021.
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-Based on observation, the license did not comply with the section above by not maintaining a clean flooring in residents' rooms which poses potential health and personal right risks to persons in care.
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Type B
10/20/2021
Section Cited
CCR
87618(b)(3)(B)&(E)
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87618 Oxygen Administration - Gas and Liquid: (b)......the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted....(E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.
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O2 tanks blocking the sliding door were removed immediately.

In addition, ALD and/or executive director to do the following and submit proof by 10/20/2021:
1. Come up with a plan on having all O2 tanks secured
2. Post O2 signage.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above. LPA observed O2 tanks blocking one of the resident room's sliding room, O2 tanks all over the place in other resident's room and no O2 signage which pose potential safety risks 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: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/01/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211001153104

FACILITY NAME:CAREFIELD CASTRO VALLEYFACILITY NUMBER:
019200685
ADMINISTRATOR:PARVEEN SINGHFACILITY TYPE:
740
ADDRESS:19960 SANTA MARIA AVETELEPHONE:
(510) 582-2765
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:116CENSUS: 45DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Katherine 'Kathy' Maningding/Assisted
Living Director		TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff did not keep the facility free of ants.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct investigation of the above allegation. LPA met with Assisted Living Director (ALD) Katherine 'Kathy' Maningding and informed the purpose of visit.

LPA conducted inspection with K. Maningding. LPA selected 4 resident's rooms for inspection. LPA also inspected the dining area and kitchen. LPA did not observed any ants in the areas inspected. Maningding indicated that there are times when there are ants outside the facility's vicinity and that the facility has contract with pest control company that comes monthly. LPA obtained copy of the contract.


....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 6
Control Number 15-AS-20211001153104
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: CAREFIELD CASTRO VALLEY
FACILITY NUMBER: 019200685
VISIT DATE: 10/06/2021
NARRATIVE
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Based on information gathered, the allegation of "Staff did not keep the facility free of ants" is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited for this allegation.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6