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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 07/16/2025
Date Signed: 07/16/2025 01:54:46 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
06/05/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250605132237
FACILITY NAME:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, JENNIFERFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 43DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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On 07/16/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

On 06/05/25 at 3PM, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, admission agreement, reappraisals, needs & services plan, physician's report, centrally stored medication logs, medication administration records, incident reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
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 5
Control Number 15-AS-20250605132237
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: COUNTRY PLACE ASSISTED LIVING
FACILITY NUMBER: 075601547
VISIT DATE: 07/16/2025
NARRATIVE
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Allegation: Staff mismanaged resident’s medication
Investigation Finding: Substantiated
During investigation, staff (ADM) and reporting party (RP) confirmed with LPA that staff failed to timely pick-up resident’s prescribed medication (Mavyret) and timely administer the medication to the resident (R1).
Review of R1’s centrally stored medication logs dated October 2023 showed R1’s prescribed medication started on 02/23/24 and was discontinued on 04/19/24. Witness (W1) also stated that facility staff failed to timely pick-up and administer R1’s prescribed medication (Mavyret).

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff mismanaged resident’s medication was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

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.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250605132237
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: COUNTRY PLACE ASSISTED LIVING
FACILITY NUMBER: 075601547
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2025
Section Cited
CCR
87465(a)(1)
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The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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By POC due date, Administrator agreed to submit to CCL completed in-service staff re-trainings on residents’ medication administration in compliance with Section 87465 (a)(1).
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This requirement was not met as evidenced by staff mismanaged resident’s medication which posed a potential health & safety risk to residents 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/05/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250605132237

FACILITY NAME:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, JENNIFERFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 43DATE:
07/16/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
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5
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9
Staff threatened resident in care
Staff did not provide proper transportation services to resident in care
INVESTIGATION FINDINGS:
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5
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13
On 07/16/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

On 06/05/25 at 3PM, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, admission agreement, reappraisals, needs & services plan, physician's report, centrally stored medication logs, medication administration records, incident reports.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250605132237
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: COUNTRY PLACE ASSISTED LIVING
FACILITY NUMBER: 075601547
VISIT DATE: 07/16/2025
NARRATIVE
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Allegation: Staff threatened resident in care
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM), responsible party (POA) and resident (R1). ADM denied threatening R1 with eviction. Review of R1’s 30-day eviction notice dated 07/01/24 showed that R1 was given written notification of the 30-day eviction due to failure to comply with facility guidelines wherein he walked into the medication office, took a staff’s wallet, removed money, credit cards/ driver’s license and then bragged to other residents about it. Responsible party (POA) stated that she convinced ADM to rescind R1’s written 30-day eviction in July 2024 and let R1 stay at the facility. During unannounced visits on 12/10/24, 06/05/25 and 07/16/25, LPA observed (R1) still residing at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff threaten resident in care is unsubstantiated.


Allegation: Staff did not provide proper transportation services to resident in care
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with staff (ADM), reporting party (RP). resident (R1) and reviewed R1’s documents. Review of R1’s signed admission agreement dated 11/11/22 showed the facility is not responsible for R1’s transportation requirements. LPA also reviewed R1’s medical records which showed his audio appointment on 01/08/25 was rescheduled at a later date due a scheduling conflict with his oncology radiation treatments. ADM confirmed with LPA that R1’s transportation was provided by a third party as arranged by R1’s case manager and R1’s family member to and from his doctors’ visits. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not provide transportation services to resident in care is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5