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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601547
Report Date: 02/18/2026
Date Signed: 02/18/2026 04:53:04 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
10/14/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20241014211018
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: 49DATE:
02/18/2026
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:YVONNE GOLDEN, MEDICATION TECHNICIANTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff are retaining a resident that requires a higher level of care
Staff do not ensure that resident's needs are met
INVESTIGATION FINDINGS:
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On 02/18/2026 at 03:05pm, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Yvonne Golden, Medication Technician (MT) and explained the reason for the visit. LPA spoke with Sherry Richardson via phone call.

During the investigation LPA interviewed W1, S1, S2, S3, and R1. LPA reviewed facility and Staff Roster, C1 face sheet, preplacement appraisal information, progress notes, Medical Administration Records (MAR). C1 Physicians Report is missing from the file.
CONTINUE ON LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
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 3
Control Number 15-AS-20241014211018
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: 02/18/2026
NARRATIVE
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CONTINUE FROM LIC9099

Allegation: Staff are retaining a resident that requires a higher level of care

Investigation Finding: unsubstantiated.

During the investigation, the LPA interviewed W1,S1, S2, S3 and R1. Interview with W1 revealed that W1 was concerned with R1 needing a higher level of care, W1 stated that the facility has clients that have mental illnesses and R1 has dementia. Interview with S1 revealed that R1 has been a resident at the facility for 9 years and has been diagnosed with dementia before being placed at the facility. S1 also stated that R1 was placed at the facility by San Francisco Department of Public Health which is a placement agency. S1 stated that R1 was living in SRO (single residence occupancy) housing and R1 became forgetful before moving to the facility S1 also stated that R1 has not had any altercations with any of the other residents living at the facility and that R1 knows and recognize the faces at the facility, R1 has had the same roommate for a very long time. Interview with S2 revealed that R1 had dementia prior to moving into the facility and R1 likes to walk a lot and R1 will work around the building and talk with other residents, there has not been any altercations with any other residents, R1 also like to talk with the residents. Interview with S3 reveals that R1 likes to walk and talk with the other residents around the facility. S3 also stated that if R1 is talking and a resident doesn’t want to talk they will just call R1s name and redirect R1. Interview with R1 revealed that R1 likes living at the facility and R1 likes to walk and sing. R1 stated that R1 likes the food, and the people are okay. THEREFORE, THIS ALLEGATION IS UNSUBSTANTIATED.

CONTINUE ON LIC9099C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241014211018
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: 02/18/2026
NARRATIVE
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CONTINUE FROM LIC9099C

Allegation: Staff do not ensure that residents’ needs are met
Investigation Finding: unsubstantiated.

During the investigation LPA interviewed W1, S1 and S3. W1 expressed concerns about R1s needs at the facility being met due to the facility type. Interview with S1 revealed that R1 has help with ADLs (activities of daily living) and sometimes if R1 needs to be prompted to eat, facility staff have been trained on dementia care. Interview with S3 revealed that S3 has had dementia care and has been working with dementia care residents for many years. S3 also stated that S3 works with R1 directly and assists with R1s ADLs and that sometimes R1 likes to sometimes shower R1s self and S3 will be there if assistance is needed. S3 also stated that R1 feeds R1 self and only sometime R1 might need staff to prompt R1 by putting the spoon in R1s hand and R1 will then feed R1s self. LPA interviewed and observed R1 eating and drinking a snack, LPA also observed R1 singing and was able to answer some interview questions. THEREFORE, THIS ALLEGATION IS UNSUBSTANTIATED.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3