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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200687
Report Date: 04/09/2021
Date Signed: 04/09/2021 02:27:30 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
11/08/2019 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20191108164531
FACILITY NAME:EDEN ASSISTED LIVINGFACILITY NUMBER:
019200687
ADMINISTRATOR:TET, SAMUELFACILITY TYPE:
740
ADDRESS:18787 CARLTON AVETELEPHONE:
(510) 885-0557
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 6DATE:
04/09/2021
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Samuel Tet, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff mismanages resident's medications.
Facility staff failed to administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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On 4/9/2021 at 2:10PM Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegations. LPA G. Luk spoke with Administrator, Samuel Tet and explained reason for the tele-visit. LPA explained due to the present shelter in place order by the Governor, delivering complaint findings is being done over video conference.

During the course of investigation, LPA interviewed 3 residents, 3 staff, and complainant. LPA reviewed 3 residents' MAR (Medication Administration Record) and doctor's order of medications. According to the doctor's order dated 6/24/2019, resident's (R2) eye drops was to be administered twice daily. However, the facility have been given the eye drops once a day as noted in the MAR for October and November of 2019.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED.
Exit interview conducted. A copy of report and appeal rights will be emailed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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 3
Control Number 15-AS-20191108164531
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: EDEN ASSISTED LIVING
FACILITY NUMBER: 019200687
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidence by:
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Administrator has agreed to retrain all staff on medication administration. Administrator will also submit a written statement that all current and future resident's medications will be reviewed with
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Based on investigation, licensee did not comply with the section cited above by not administering eye drops according to doctor's order which poses an immediate health and safety risk to the residents in care.
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doctor's order and MAR to ensure all medications are administered correctly. Administrator will submit staff training document and written statement to CCLD by POC date.
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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: 04/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
11/08/2019 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20191108164531

FACILITY NAME:EDEN ASSISTED LIVINGFACILITY NUMBER:
019200687
ADMINISTRATOR:TET, SAMUELFACILITY TYPE:
740
ADDRESS:18787 CARLTON AVETELEPHONE:
(510) 885-0557
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 6DATE:
04/09/2021
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Samuel Tet, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Facility staff are unable to communicate due to language barrier.
INVESTIGATION FINDINGS:
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On 4/9/2021 at 2:10PM Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegation. LPA G. Luk spoke with Administrator, Samuel Tet and explained reason for the tele-visit. LPA explained due to the present shelter in place order by the Governor, delivering complaint findings is being done over video conference.

During the course of investigation, LPA interviewed 3 residents, 3 staff, and complainant. Interview with staff (S1) revealed that all staff does speak English, but English is their second language. On 11/14/2019, LPA was able to interview all the staff in English. LPA observed that all staff were able to communicate in English.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation are UNSUBSTANTIATED.

Exit interview conducted and a copy of report will be emailed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3