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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200685
Report Date: 06/04/2025
Date Signed: 06/04/2025 02:25:01 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
08/24/2022 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20220824162155
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: 71DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Parveen Singh, Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Lack of supervision resulted in resident sustaining in multiple fractures from unwitnessed falls.
INVESTIGATION FINDINGS:
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On 6/04/2025 at 1 p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Executive Director Parveen Singh, explained the purpose of the visit.

Allegation: Lack of supervision resulted in resident sustaining in multiple fractures from unwitnessed falls- Substantiated

On 09/07/2022, The department reviewed the record of R1, including medical record, care note, facility’s protocol, and staff interview.

Report continued on LIC 9099c...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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 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
08/24/2022 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20220824162155

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: 71DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Parveen Singh, Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility administered controlled substance without doctor's orders.
Facility failed to meet resident's needs.
Lack of care resulted in resident sustaining multiple urinary tract infections
INVESTIGATION FINDINGS:
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On 6/04/2025 at 1:30 p.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Executive Director Parveen Singh, explained the purpose of the visit.

Allegation: Facility administered controlled substance without doctor's orders. Unsubstantiated

It was alleged facility administered controlled substances without a doctor’s orders. On 09/07/2022, the department reviewed the record of R1, including but not limited to doctor orders, and Mars shows that the medication that the facility administered controlled substance, does have a doctor's order.

Reports continued on LIC 9099c...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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-20220824162155
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: 06/04/2025
NARRATIVE
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Allegation: Facility failed to meet the resident's needs. Unsubstantiated

It was alleged facility failed to meet the resident’s needs, however, the department conducted staff interviews, reviewed R1’s assessments, and the care plan shows R1 does not need a one-on-one for all three R1 assessments, dated 10/2/2021, 2/17/2022, and 8/25/2022. However, R1 was to have 4 to 8 status checks per shift by a caregiver.

After this incident, S3, S2, and S1 all decided to "have more eyes" on R1. "Having more eyes" means checking on R1 more. S6 told caregivers to watch R1 and R1's behavior. After R1 falls and R1 comes back from the hospital, the staff would monitor R1 more frequently and follow R1's discharge instructions

During safety checks on R1, S9 would "pop in" the R1 room. Check to see if R1 was breathing or sitting. Checks were quick and lasted about two minutes. For the PM shift, S9 checks on residents about three to four times. S9 would always check on R1 before S9 left. Checks are not being documented.

On 3/22/23 S6, S7, and S9 stated R1 refused to get change and bathing most time, and when R1 does want assistance, it depend on R1 mood. However, most time R1 doesn’t want to get assistant with ADL because to R1, R1 think R1 can still manage by R1 that R1 is still independent.

Conducted interviews with S1, S2, S3, S4, S6, S7, S8, S9, S10, and HHN stated R1 is being checked 4 to 8 times, and always with a staff member.

Report continues on KIC 9099c...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20220824162155
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: 06/04/2025
NARRATIVE
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Allegation: Lack of care resulted in resident sustaining multiple urinary tract infections. Unsubstantiated

On 6/18/2021, R1 was admitted to the assisted living side of Carefield Castro Valley. R1 had been in and out of the hospital during R1's time at the facility. R1 was transported to Kaiser in San Leandro in January 2022, due to urinary tract infection (UTI), followed by COVID-19, and low platelets. Records reviews R1’s contacted UTI on 1/17/2022, 7/13/2022, and 8/23/22. However, before the three different events that R1 contracted, UTI S1 had requested R1 to get a check-up. S1, S6, S7, S8, and S9 encouraged R1 to drink more water, but R1 asked to be left alone. Staff stated they cannot force anyone to do anything they don’t want; they can only encourage.

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 conducted and a copy of this report are provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20220824162155
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: 06/04/2025
NARRATIVE
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Based on interviews of staff at the Carefield Castro Valley facility, R1 was admitted on 6/18/2021 and was transferred from the Assisted Living side of the facility to the Memory Care side on 2/18/2022 because of R1’s dementia diagnosis and a recommendation from Kaiser Memory Care Clinic for R1 to be in Care. Memory Care staff and documents show a history of seven falls from 5/4/2022 to 8/17/2022. Staff statements show R1 was considered a fall risk and that R1’s condition had changed both mentally and physically. Staff statements confirmed that R1 believed R1 could stand up and walk without assistance, however, R1 would fall and sustain multiple unwitnessed falls while being in R1’s room. Staff were aware to frequently check on R1, however, R1 fell multiple times. S1 stated S1 would keep R1 with S1 while working because S1 wanted to keep a closer eye on R1, however, the evidence does not show S1 gave any instructions to direct care staff to provide care and supervision to R1 to prevent R1 from falling in R1 room.

Although facility staff were aware of R1's multiple falls, they failed to take adequate measures to ensure R1’s safety, resulting in multiple falls and/or being found on the floor in R1's room. R1 was sent by the facility to Kaiser on 5/4/2022, 7/11/2022, 7/13/2022 (twice), 8/17/2022, and 8/23/2022. R1 was diagnosed with fractured ribs on 7/13/2022 and a fracture to the T9-T10 vertebrae on 8/17/2022.


Based on evidence obtained during the course of this investigation, the Department has determined that lack of supervision resulted in resident sustaining multiple fractures from unwitnessed falls. This is a factual determination based on all the facts and circumstances of the case. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.


Exit interview conducted. Appeal Rights and a copy of this report are provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20220824162155
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: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87411(a)
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87411
Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

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By POC date, Excutive Director agrees to review regulation and submit self-certification letter stating the understand of regulation.
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Based on evidence obtained during the course of this investigation, the Department has determined that lack of supervision resulted in resident sustaining multiple fractures from unwitnessed falls. This is a factual determination based on all the facts and circumstances of the case.
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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: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6