019200750-2-12-2025-15-AS-KHOS-DJZMP2-20250728094625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200750
Report Date: 02/12/2025
Date Signed: 02/12/2025 05:31:11 PM

Unsubstantiated

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
02/04/2025 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20250204131826

FACILITY NAME:	SCOTT VILLA		FACILITY NUMBER:	019200750
ADMINISTRATOR:	JONABELLE TOLENTINO		FACILITY TYPE:	740
ADDRESS:	1560 MIDDLE LANE		TELEPHONE:	(510) 782-7833
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	35	CENSUS: 34	DATE:	02/12/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Lulin 'Lucy' Wu/Back-up Administrator		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Staff are not distributing a resident's medication as prescribed.

INVESTIGATION FINDINGS:

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At 1:45 pm on this day, 2/12/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Adrianne 'Diane' Manalastas. Lulin 'Lucy' Wu, back-up administrator (BUA), arrived at around 2:05 pm. LPA informed the purpose of visit.

The reporting party (RP) stated the resident moved-in to RP's facility, and that the staff of Scott Villa
could not state when the resident was distributed the last dose of medication and that staff had difficulty understanding questions and finding information on the Medication Administration Record (MAR). RP reported that the med-tech appeared to have no understanding of the medications, what they were for, or any concern for information they were providing. RP further stated that the resident had seizure medication given in morning and that staff stated the medication was last given the day before. However, RP did not provide information who is the resident is and the facility staff and medications.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250204131826

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: SCOTT VILLA	FACILITY NUMBER: 019200750
	VISIT DATE: 02/12/2025

NARRATIVE

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LPA obtained copies of LIC9020 Register of Facility Residents for 10/14/24, 12/31/24 and 2/07/25. LPA reviewed and compared the 3 LIC9020s and observed 4 residents (R1, R2, R3, R4) listed on 10/14/24 LIC9020 were no longer on the 2/07/25 LIC9020. LPA reviewed these residents' records and obtained copies of including but not limited to the following: Admission Agreement; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-placement Appraisal; LIC625 Appraisal/Needs and Services Plan; facility notes; doctor's orders of medications; Medication Administration Records (MARs); LIC622 Centrally Stored Medication and Destruction Records. Out of these 4 residents, only R1 has seizure medications. The other 3 did not have seizure disorder diagnosis nor seizure medications.

LPA interviewed S1, S2 and BUA. S1 and S2 denied receiving calls for R1, R2, R3 and R4 pertaining to medications. BUA stated when Jonabelle Tolentino (administrator) went on vacation, S3 took over the administration of medications from around 12/28/24 through 1/08/25, 1/09/25. BUA also stated that S1 took over the administration of medications when S3 went on vacation up until this day, 2/12/25, which LPA confirmed with S1. LPA reviewed the doctor's order of medications and compared with LIC622 and MAR. Review of records showed S1 has medication training and R1's MAR were properly filled-up.

Based on records review and interviews, the allegation of 'Staff are not distributing a resident's medication as prescribed' is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

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