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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201341
Report Date: 12/16/2025
Date Signed: 12/16/2025 03:49:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
12/11/2025 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251211101359
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:
12/16/2025
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Khin Win, CaregiverTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff did not ensure showers were clean
Staff did not ensure medications were locked and inassesable to residents
INVESTIGATION FINDINGS:
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On 12/16/2025 at 12:50 PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct an initial 10-day complaint investigation in regards to the allegations above. LPA called Licensee/Administrator, Thinn Aye, and explained the purpose of the visit over the phone. Thinn gave authorization for caregiver, Khin Win, to sign the report.

During the visit LPA toured the facility with Staff (S1) and observed that the individual locks on each locker that holds the residents' medications were not securely locked. LPA observed that the shower floors were not clean.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are 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 with Khin Win. Appeal rights and copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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 2
Control Number 15-AS-20251211101359
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ALONDRA CARE HOME
FACILITY NUMBER: 019201341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator agreed to conduct an In-Service training with all 3 caregivers on the regulation, keeping medications locked and inaccessible to residents. Training sign-in sheet with synopsis will be submitted to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above by having the individual locks on each locker unlocked which poses an immediate health and safety or personal rights risk to persons in care.
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During visit caregiver locked each individual lock on each locker.
Type B
12/23/2025
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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Administrator agreed to clean the bathroom shower floors and flooring and will submit a photo of shower floors and surfaces clean. In addition, Administrator will conduct an In-Service training with all 3 caregiver staff on keeping and maintaining the facility clean including but not limited to shower floor surfaces. Training sign-in sheet will be submitted to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above by not having the shower floors and flooring in bathroom clean which poses a potential health, safety or personal rights risk to persons in care.
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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: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2