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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601208
Report Date: 11/01/2024
Date Signed: 11/01/2024 02:05:50 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
09/01/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230901131403
FACILITY NAME:HM LOVE & CARE HOMEFACILITY NUMBER:
075601208
ADMINISTRATOR:RIFORMO, HAILEY R.FACILITY TYPE:
740
ADDRESS:508 KAYANN COURTTELEPHONE:
(510) 222-1406
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 4DATE:
11/01/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Maria Riformo, LicenseeTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility did not seek medical attention for resident in a timely manner for a hip fracture
Facility did not meet resident's medical needs
Facility retaliated for filing a complaint
Facility did not safeguard resident’s personal belongings
Staff left resident with feces for extended periods of time
Facility overcharged resident
INVESTIGATION FINDINGS:
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On 11/1/2024 at 1:20pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Susana Cunanan, Caregiver. Licensee, Maria Riformo, arrived at 1:35pm and LPA and explained the reason for the visit.

During the investigation the Department interviewed the reporting party (RP), staff, obtained and reviewed R1’s records.

Allegation: Facility did not seek medical attention for resident in a timely manner for a hip fracture.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
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 4
Control Number 15-AS-20230901131403
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: HM LOVE & CARE HOME
FACILITY NUMBER: 075601208
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC9099.

On 7/31/2023 R1’s family arrived at the facility to take R1 to a doctor’s appointment. The family took R1 away from the facility in their private vehicle. R1 was then admitted into Contra Costa Regional Medical Center with a complaint of neglect/abuse and dementia. The Department requested and reviewed medical records from Contra Costa Regional Medical Center dated 7/1/2023 to 10/06/2023. Record review indicated R1 was admitted to Contra Costa Regional Medical Center on 7/31/2023. Hospital staff conducted a medical work up which included an x-ray and CT head. The x-ray returned with no evidence of a fracture. Based on medical records and facility records there is not enough information to state the need for medical attention on that particular date.

Allegation: Facility did not meet resident's medical needs

During interview with RP it was stated that R1 had multiple bruises, malnourished, a vitamin deficiency, hip fracture, and had sustained a stroke while in care. Record review of Contra Costa Regional Medical Center records dated 7/31/2023 indicates R1 had bruising but not from abuse or neglect, no fracture, no stroke, no vitamin deficiency, or malnourishment. Record did state that a supplementation should be considered for R1. S1 stated R1 had been living at the facility for approximately 10 years and has slowly been declining and had to be reminded to eat.

Allegation: Facility retaliated for filing a complaint

During initial interview RP stated facility retaliated due to a previous complaint towards the facility. During S1’s interview she stated that R1’s family member

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20230901131403
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: HM LOVE & CARE HOME
FACILITY NUMBER: 075601208
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC9099C.

arrived to take R1 to an appointment that had been canceled. S1 stated due to the family’s previous history at the facility she denied entrance because she did not feel safe not to retaliate, and the Contra Costa Sheriffs were called to help with the situation.

Allegation: Facility did not safeguard resident’s personal belongings

During initial interview RP stated R1’s belongings had mildew on it. RP submitted a photo that showed three (3) pair of shoes. Two (2) shoes had some unknown material on them but during review LPA could not distinguish if it was mildew, dust, or dirt. The photo was taken outside on the cement at unknown location.

Allegation: Staff left resident with feces for extended periods of time

RP stated when R1 was removed the facility and taken to the Contra Costa Medical Center R1’s diaper had not been changed and there was crusted feces in her diaper. RP submitted photos as documentation. LPA reviewed photos and observed a small amount of something brown in color on diaper and on the body of the person in the photograph. However, there isn’t enough evidence to suggest that staff left resident with feces for an extended period of time.

Allegation: Facility overcharged resident

RP stated during initial interview that R1 had been charged for appointments but had not been seen by the primary physician since October 2022. S1 stated the facility do not charge for doctor appointments. Review of the admission agreement under basic services item 7 indicates the family is responsible for transporting the resident to medical or dental appointments.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20230901131403
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: HM LOVE & CARE HOME
FACILITY NUMBER: 075601208
VISIT DATE: 11/01/2024
NARRATIVE
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Continued from LIC9099C.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4