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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601570
Report Date: 09/09/2024
Date Signed: 12/18/2024 10:20:11 AM

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
08/30/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240830165258
FACILITY NAME:WELCOME HOME SENIOR RESIDENCE(CONCORD)FACILITY NUMBER:
075601570
ADMINISTRATOR:CHOU, STEVEFACILITY TYPE:
740
ADDRESS:1780 PEACH PLACETELEPHONE:
(510) 685-8388
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
09/09/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Steve Chou, Licensee TIME COMPLETED:
11:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's hygiene needs are not being met
Facility is not following the resident's special diet
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/09/2024 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Administrator Steve Chou.

During the initial 10-day complaint visit. LPA interviewed staff, and collected the following documents resident (R1) admissions agreement, Physicians report, needs and services plan, Power of Attorney, and preplacment appraisal.

On the allegation Resident's hygiene needs are not being met. S3 stated that they bath R1 once a week. S3 explained that R1 does not like to use the hoyer lift and prefers bed baths while sitting.
On the allegation Facility is not following the resident's special diet, S1 stated that R1 is on a low sodium diet and is only served her soft foods.
Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
Exit interview conducted and a copy of this report provided
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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