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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 02:11:56 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-20250605093548
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:
02:00 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not provide designated smoking areas for the residents
Staff did not have planned activities for the residents
INVESTIGATION FINDINGS:
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On 07/16/25 at 2PM, 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 2:38 PM, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, 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-20250605093548
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 did not provide designated smoking areas for the residents
Investigation Finding: Substantiated
During investigation, LPA confirmed with staff (ADM) and reporting party (RP) that all 43 residents (7 positive and 32 negative residents) were confined to their rooms due to a COVID-19 outbreak lockdown which started on 05/08/25 until 06/05/25. Approximately 11 to 12 residents who smoke cigarettes had their right to smoke taken away from them by staff as part of the COVID-19 lockdown period (05/08/25 until 06/05/25). 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 did not provide designated smoking areas for the residents was found to be substantiated.


Allegation: Staff did not have planned activities for the residents
Investigation Finding: Substantiated
During investigation, ADM and third-party witness (W1) confirmed with LPA that due to the COVID-19 outbreak that started on 05/08/25, staff suspended all common area activities for all 43 residents (7 positive and 32 negative residents) which included smoking in the smoking post outside areas, watching TV and relaxing in the living room / garden areas. Staff confined all 43 residents inside their rooms with no planned activities offered while in isolation from 05/08/25 until 06/05/25. 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 did not have planned activities for the residents was found to be substantiated.

Deficiencies are 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
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-20250605093548

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:
02:00 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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2
3
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5
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7
8
9
Staff yell and mistreat the residents while in care
Staff use inappropriate language towards the residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/16/25 at 2PM, 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 2:38 PM, LPA conducted interviews with staff, random residents and obtained the following documents from ADM: Personnel record (LIC500), Residents roster, 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: 3 of 5
Control Number 15-AS-20250605093548
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 yell and mistreat the residents while in care
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with reporting party (RP), random residents (R1, R2, R3) and staff (ADM). RP stated that several residents (names unknown) expressed fear of asking anything other than their daily meals and medications due to staff yelling at them and treating them indifferently. LPA interviewed random residents (R1, R2, R3) who stated that staff are OK and do not mistreat or yell at them. ADM stated that she has not observed any staff mistreat or yell at any residents at the facility. During unannounced visits on 12/10/24, 06/05/25, 07/16/25, LPA observed staff did not yell or mistreat any residents when assisting them with their activities of daily living (ADLs). 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 yell and mistreat the residents while in care is unsubstantiated.


Allegation: Staff use inappropriate language towards the residents
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with reporting party (RP), random residents (R1, R2, R3) and staff (ADM). RP stated that several residents (names unknown) said that staff are rude and curse at them when requesting assistance. LPA interviewed random residents (R1, R2, R3) who stated that staff assist them with their needs, give them their daily meals/snacks/drinks and medications without cursing at them. ADM stated that she has not observed any staff curse at any resident at the facility. During unannounced visits on 12/10/24, 06/05/25, 07/16/25, LPA observed staff did not curse at residents when assisting them with their activities of daily living (ADLs). 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 use inappropriate language towards the residents 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: 4 of 5
Control Number 15-AS-20250605093548
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
87468.2(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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By POC due date, Administrator agreed to complete and submit to CCL in-service staff re-trainings b a CCLD approved vendor on residents’ personal rights in compliance with Section 87468.2(a)(4).
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This requirement was not met as evidenced by staff did not provide designated smoking areas for the residents which posed a potential health & safety risk to residents in care.
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Type B
08/11/2025
Section Cited
CCR
87468.1(a)(5)
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To have the freedom to attend religious services or activities of their choice either in or outside the facility and to have visits from the spiritual advisor of their choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis.
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By POC due date, Administrator agreed to complete and submit to CCL in-service staff re-trainings b a CCLD approved vendor on residents’ personal rights in compliance with Section 87468.1(a)(5).
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This requirement was not met as evidenced by staff did not provide planned activities for the residents during COVID lockdown which posed a potential health and 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: 5 of 5