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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601218
Report Date: 07/06/2021
Date Signed: 07/06/2021 12:15:26 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
06/25/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210625085913
FACILITY NAME:ABEL CARE HOME IIIFACILITY NUMBER:
075601218
ADMINISTRATOR:MATIAS, JERRYFACILITY TYPE:
740
ADDRESS:881 PLA VADA COURTTELEPHONE:
(925) 798-9196
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
07/06/2021
UNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Administrator, Lailo MatiasTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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9
Staff did not respond to resident's call for assistance
INVESTIGATION FINDINGS:
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On 07/06/2021 at approximately 9:31am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a 10-day initial complaint opening. LPA met with Staff, Elenonor Delos Santos. Administrator Lailo Matias arrived at approximately 9:40am. LPA Catherine Lin arrived at approximately 11:00am.

During visit, LPAs interviewed three staff and four residents that use pendents. LPAs reviewed staff schedule, staff roster, physician reports, needs and services plans and resident roster. LPAs observed facility's pendent call system. During staff interviews, it was revealed that there have been occurences when residents have used the pendant while a staff is helping another resident. However, staff have not taken longer than 15 minutes to answer residents' pendents.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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-20210625085913
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: ABEL CARE HOME III
FACILITY NUMBER: 075601218
VISIT DATE: 07/06/2021
NARRATIVE
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The Department has investigated these allegations and based upon LPAs' observations, interviews conducted, and records reviewed, the allegation is found to be 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 evidence to prove that the alleged violation has occurred.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2