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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601495
Report Date: 05/07/2021
Date Signed: 05/10/2021 03:08:21 PM

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
05/06/2021 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210506145449
FACILITY NAME:J. CABRAL ELDER CARE,LLCFACILITY NUMBER:
075601495
ADMINISTRATOR:CABRAL, MARIA JOCELYN S.FACILITY TYPE:
740
ADDRESS:5500 KELROSE COURTTELEPHONE:
(925) 673-1237
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
05/07/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jocelyn CabralTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility makes false claims regarding employee training.
Staff have not received required training.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analysts (LPAs) Luisa Fontanilla and Carol Fowler conducted a televisit via Zoom and met with Administrator Jocelyn Cabral. LPA Luisa Fontanilla explained to Administrator the purpose of televisit.

During the visit, LPAs interviewed Administrator. Administrator confirmed with LPAs that two staff, S1 and S2
obtained their First aid/CPR certificates without appropriate training.

Based on interview conducted, the preponderance of evidence standard has been met, therefore the above allegations are substantiated. California Code of Regulations, Title 22 are being cited on the attached Lic9099D.

A copy of this report will be provided to Adminstrator via email.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
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-20210506145449
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: J. CABRAL ELDER CARE,LLC
FACILITY NUMBER: 075601495
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited
CCR
87411
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Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
Based on interview conducted, Administrator confirmed with LPAs that S1 and S2
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By POC date, Administrator states proof of First aid/CPR training will be sent to CCL.
Note: Facility is conducting live class on First aid/CPR today and Administrator states proof of training will be sent to CCL.
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obtained their First aid/CPR certificates renewal without appropriate training which poses a potential risk to health and safety of residents under care.
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Type B
05/14/2021
Section Cited
CCR
87405(d)(2)
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Administrator - Qualifications and Duties
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

Based on interview, Administrator confirmed with LPAs she was aware that S1 and S2 obtained certificates without the appropriate training.
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By POC date, Administrator states that she will review Sec 87405 and submit certificate of understanding of Sec 87405 to CCL.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2