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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 071440165
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:02:31 AM

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
05/15/2023 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20230515133330
FACILITY NAME:ABRAHAM REST HOMEFACILITY NUMBER:
071440165
ADMINISTRATOR:ABRAHAM, SARAFACILITY TYPE:
740
ADDRESS:116 VIA MONTETELEPHONE:
(925) 944-5218
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Sara AbrahamTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility front door is equipped with a inappropriate lock
INVESTIGATION FINDINGS:
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On 05/15/2023 at 8:20 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an initial 10-day investigation regarding the above allegation. LPA explained the purpose of the visit to staff. Administrator Sara Abraham arrived at 10:45 AM.

LPA confirmed inappropriate lock on front upon entering facility. During a tour of the facility, 3 other sliding glass exit doors were "locked" in place with poles blocking movement of the glass door, thereby blocking exit.

When asked, Caregiver Claudia de la Cruz confirmed what had been stated by Complainant that it was used to block residents' exit. Based on the data collected by observation and interview, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED.

Deficiency cited per Title 22 California Code of Regulations is listed on the LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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-20230515133330
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: ABRAHAM REST HOME
FACILITY NUMBER: 071440165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in all Facilities: (a) Residents in all residential care facilities for the elderly shall ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Licensee removed front door lock during visit.
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Based on observation, the licensee did not comply with the section cited above by locking the front exit door from the inside, which poses an immediate 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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2