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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200922
Report Date: 12/05/2024
Date Signed: 12/05/2024 06:12:29 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
11/27/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20241127165044
FACILITY NAME:MORNINGSTAR SENIOR LIVING OF HAYWARDFACILITY NUMBER:
019200922
ADMINISTRATOR:HENRY, CAYIAFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:170CENSUS: 105DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Rosana Frias/Associate Executive DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff not ensuring resident's room is clean and not keeping the facility free of insects.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Associate Executive Director (AED) Rosana Frias and informed the reason for visit.

LPA obtained copy of resident roster and inspected four residents' apartments. LPA also interviewed residents (R1, R2 and R3), resident's family member (FM), staff (S1, S2, AED), witness (W1).

R1, R2, FM, S1 and S2 all stated observing roaches. R3 stated observing roaches in her apartment a while ago and recently observed and killed a bug in her apartment. FM stated observing roaches in the residents' apartment and the apartment is filthy and that the staff are not making sure that the apartment is kept clean. FM further stated that roach traps had been sitting in the residents' kitchen counter for months.

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

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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-20241127165044
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: MORNINGSTAR SENIOR LIVING OF HAYWARD
FACILITY NUMBER: 019200922
VISIT DATE: 12/05/2024
NARRATIVE
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During inspection, LPA observed roach traps with dead roaches in 2 residents apartments. LPA also observed dead roach in the kitchen cabinet in 1 of the apartments and stained carpet flooring and mattress leaning on the wall in this apartment, and another apartment with litter.

Based on interviews and observation, the preponderance of evidence has been met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation of section 87303(a) within 12 month period. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency and plan and proof of correction were discuss with AED.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241127165044
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: MORNINGSTAR SENIOR LIVING OF HAYWARD
FACILITY NUMBER: 019200922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2024
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.

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AED stated she'll do the following and submit proof by 12/19/24.
1. Have the apartments cleaned.
2. Have the pest control company come
once a week .
3. Come up with a plan of ensuring the insects are eradicated completely.
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-This requirement is not met as evidenced by:
-Based on interviews and observation, the licensee did not comply with the section above in residents aparments not kept cleaned and free of insects which pose a potential health, safety and personal rights risks to persons in care. This is a repeat vioation
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A $250.00 is assessed.
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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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3