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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200727
Report Date: 11/16/2023
Date Signed: 11/16/2023 06:11:27 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
11/14/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231114125227
FACILITY NAME:FLINTWOOD CARE HOMEFACILITY NUMBER:
019200727
ADMINISTRATOR:HOLT, JEANFACILITY TYPE:
740
ADDRESS:36614 FLINTWOOD DRIVETELEPHONE:
(510) 742-5680
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:6CENSUS: 2DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Jean HoltTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff do not provide resident with proper catheter care.
Staff do not provide resident with activities.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct investigation on the above allegations. LPA was met by Administrator Jean Holt.

During the course of investigation, LPA interviewed staff and Resident 2 (R2). LPA attempted to interview Resident 1 (R1) but failed LPA reviewed records for two residents. LPA inspected all resident bedrooms.

Based on file review and interviews conducted, facility does not have proof of staff training for R1's catheter. R1 goes to the Veterans Hospital for catheter change. Staff drain the bag and monitor R1 for signs and symptoms of of infection. There is no proof of staff training on file. Administrator states staff were trained but do not have the proof of training.

continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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 5
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
11/14/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231114125227

FACILITY NAME:FLINTWOOD CARE HOMEFACILITY NUMBER:
019200727
ADMINISTRATOR:HOLT, JEANFACILITY TYPE:
740
ADDRESS:36614 FLINTWOOD DRIVETELEPHONE:
(510) 742-5680
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:6CENSUS: 2DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Jean HoltTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure resident's room is kept clean.
Facility does not have appropriate staffing to meet resident's needs
Staff does not treat resident with respect.
INVESTIGATION FINDINGS:
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10
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12
13
LPA Luisa Fontanilla arrived at the facility to conduct investigation on the above allegations and met with Administrator Jean Holt. LPA explained to Jean the purpose of the visit.

During the course of investigation, LPA inspected the facility inside and out. LPA observed the facility and resident bedrooms appeared to be clean and odor free.

LPA obtained a copy of Lic 500 and observed the Administrator lives at the facility 24/7. Staff 1 (S1) is also a livein staff who works from Monday-Friday 8am-8pm. Staff 2 (S2) is the on call staff who works on Saturday and Sunday from 8am-8pm while facility is in the process of hiring an additional staff.

While at the facility, LPA interviewed Administrator, S1 and R2. LPA attempted to interview R1 but was unable to obtain appropriate response.
continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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 5
Control Number 15-AS-20231114125227
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: FLINTWOOD CARE HOME
FACILITY NUMBER: 019200727
VISIT DATE: 11/16/2023
NARRATIVE
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R2 states that R2 likes living at the facility. R2 states R2 likes the staff and the foods.

Staff interviewed state that they respect and treat all residents the same way. Staff interviewed denied mistreating or disrespecting any resident at the facility. Based on interviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20231114125227
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: FLINTWOOD CARE HOME
FACILITY NUMBER: 019200727
VISIT DATE: 11/16/2023
NARRATIVE
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During the visit, LPA observed R1 sitting in the wheelchair in the living area. R2 was observed sitting in the dining area. LPA did not observe any activity conducted by staff during the visit.

Based on observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20231114125227
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: FLINTWOOD CARE HOME
FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2023
Section Cited
CCR
87613(a)(2)
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87613 General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

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Administrator and staff will undergo training on R1's catheter and submit proof to CCL by POC date.
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This requirement is not met as evidenced by:
Licensee did not comply with section cited by not providing appropriate training to R1 who has catheter.
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Type B
11/29/2023
Section Cited
CCR
87705(c)(7)
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87705 Care of Persons with Dementia
(7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation.
This requirement is not met as evidenced by:
Licensee did not comply with section cited
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Administrator will create activity calendar and make sure facility provides activities. A copy of the calendar will be sent to CCL by POC date.
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for failing to provide residents with activities.
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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: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5