<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201341
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:50:42 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
01/22/2025 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20250122122719
FACILITY NAME:ALONDRA CARE HOMEFACILITY NUMBER:
019201341
ADMINISTRATOR:KUPPUSAMY, NIRMALAFACILITY TYPE:
740
ADDRESS:1643 101ST AVETELEPHONE:
(510) 509-4635
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY:6CENSUS: 5DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nini Myint, Care GiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to issue proper refund.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/19/25 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegations above. LPA met with Nini Myint, Care Giver and explained the purpose of the visit. LPA spoke with Licnesee Thinn Aye who gave permission for care staff to sign the report.

During the course of the investigation LPA interviewed W1 and S1. LPA also reviewed R1's Admission Agreement and the invoice that was sent to R1's Responsible Party (RP) for food and items that were damaged during R1’s time at the facility.

W1 and S1 both stated that R1 lived at the facility for a period of 6 days. Upon discharge S1 sent R1’s RP an invoice for extra food and items that S1 claimed R1 damaged while at the facility.

***report continues on LIC9099c***


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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-20250122122719
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: ALONDRA CARE HOME
FACILITY NUMBER: 019201341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2025
Section Cited
CCR
875079g)(3)2
1
2
3
4
5
6
7
87507 Admission Agreements: (g) Admission agreements shall specify the following:(3) Payment provisions, including the following: 2 .A comprehensive description of and the corresponding fee schedule for all basic services not included in the single fee shall be listed.
1
2
3
4
5
6
7
Licensee to issue a full refund to R1's RP by POC date.
8
9
10
11
12
13
14
Based on observation the licensee did not comply with the section cited above. License failed to issue a full refund tto R1's RP which poses an potential health, safety or personal rights risk to persons in care.

8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250122122719
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: ALONDRA CARE HOME
FACILITY NUMBER: 019201341
VISIT DATE: 02/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***report continues from LIC9099***

Review of R1’s Admission Agreement revealed no provision for the facility to charge residents for extra food or damage they may have caused to the facility.


Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted, a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3