075601041-4-7-2023-15-AS-YFLS-CSSVKT-20230614163048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601041
Report Date: 04/07/2023
Date Signed: 04/07/2023 02:03:59 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
04/11/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220411100258

FACILITY NAME:	GINES RESIDENTIAL CARE HOME III		FACILITY NUMBER:	075601041
ADMINISTRATOR:	GINES, ERLINDA		FACILITY TYPE:	740
ADDRESS:	2565 STONE VALLEY ROAD		TELEPHONE:	(925) 743-1146
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 5	DATE:	04/07/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Erlinda Gines, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Financial abuse.
Staff are not meeting the needs of the resident.
Staff are not allowing the family to visit the resident.
Staff attempted to take clothing from a family member of the resident.
Staff are over medicating the resident.

INVESTIGATION FINDINGS:

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On 4/7/2023 starting at 10:05 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. Upon arrival, LPA was greeted by care staff, Jose Pisco and LPA explained the purpose of the visit. Administrator, Erlinda GInes later arrived at 10:48 AM.

During the course of the investigation, LPA L. Hall conducted initial 10-day complaint visit on 4/18/22 and obtained the following documents for R1, R2 and R3: physician's report, appraisal needs and services, emergency contact and identification, centrally stored medication, conservator document, and admission agreements. On 4/7/23, LPA L. Francisco reviewed records, collected additional documents and interviewed staff and residents.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220411100258

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: GINES RESIDENTIAL CARE HOME III	FACILITY NUMBER: 075601041
	VISIT DATE: 04/07/2023

NARRATIVE

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Allegation: Financial abuse
Based on information obtained, R1 is being charged more than the agreed amount and check was deposited without providing an invoice. On 4/7/23, LPA reviewed R1's admission agreement and confirmed that the amount R1 is being charged is consistent with the admission agreement signed by R1's conservator. During record review, LPA observed a check was issued on 6/7/2019 to the facility for the balance due for 7/1/2019 plus the previous unpaid balance from 2/15/2019 to 5/31/2019.

Allegation: Staff are not meeting the needs of the resident
LPA interviewed R2 and R3 and both residents stated staff are meeting their needs. LPA attempted to interview R1 and LPA was unable to obtain additional information.

Allegation: Staff are not allowing the family to visit the resident
Based on record review, LPA observed a communication between facility and R1's conservator revealing that facility is not required to inform R1's conservator of visitation by F1 as of 4/15/2022. W1 confirmed that the facility was to notify R1's conservator prior to allowing visitors to visit R1.

Allegation: Staff attempted to take clothing from a family member of the resident
Based on interview with 3 staff, 3 of 3 staff stated that any excess clothes that R1 does not wear is stored in R1's luggage. LPA interviewed 2 residents and 2 of 2 residents stated they have not had any issues of items missing.

Allegation: Staff are over medicating the resident
Based on information obtained, resident is being over medicated and there is no doctor's order for R1's medications. Based on record review, LPA observed a doctor's order for R1's medications on file.

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

Exit interview conducted and a copy of this report provided to Administrator.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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