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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201146
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:00:35 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
08/25/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230825120429
FACILITY NAME:ANASTASIAFACILITY NUMBER:
019201146
ADMINISTRATOR:MAHLER, OCTAVIANFACILITY TYPE:
740
ADDRESS:3646 EAST AVENUETELEPHONE:
(510) 692-7785
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 6DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Vanesia Duhaney, CaregiverTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not ensure that resident was adequately fed resulting in weight loss
Staff did not assist resident in transferring out of bed.
INVESTIGATION FINDINGS:
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On 9/26/2024 at 10:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with caregiver, Vanesia Duhaney and explained the purpose of the visit. LPA spoke with administrator, Lacy Vincent who stated caregiver can sign CCLD reports.

During the investigation, LPA interviewed 4 residents, 2 staff, witness, and complainant. LPA reviewed and obtained documents including LIC500, physician's report, preplacement appraisal, care plan, facility notes, feeding instructions, home health document, and emergency information.

Staff did not ensure that resident was adequately fed resulting in weight loss
Interview with staff and witness revealed that staff are feeding R2 three meals daily. Interview with residents indicated that staff is providing meals to residents. R2 stated that staff assist in feeding and R2 had an appetite in the morning. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 2
Control Number 15-AS-20230825120429
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: ANASTASIA
FACILITY NUMBER: 019201146
VISIT DATE: 09/26/2024
NARRATIVE
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R2's physician's report dated 10/21/2022 shows that R2's weight was168.8 pounds. However, the facility did not have records of R2's weight after admission to the facility.

Staff did not assist resident in transferring out of bed.
Interview with residents revealed that staff are assisting residents in transferring out of bed. R2 stated that staff would assist R2 in transferring to wheelchair when asked. Interview with staff indicated that R2 doesn't want to be transferred out of bed.

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

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2