<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601574
Report Date: 04/09/2021
Date Signed: 04/09/2021 05:02:36 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
04/09/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210409095646
FACILITY NAME:SANS SOUCIFACILITY NUMBER:
075601574
ADMINISTRATOR:JENETTE COPEFACILITY TYPE:
740
ADDRESS:330 EL DIVISADERO AVENUETELEPHONE:
(925) 949-8475
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
04/09/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Katherine Grutas, AdministratorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/09/21 at 4:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced tele-visit with administrator as a result of a complaint received regarding broken floor tiles in the master shower at the facility. Due to COVID-19 shelter in place order, administrator was not physically available to sign this report.

During the tele-visit, LPA observed the main shower flooring had missing & broken tiles around the shower drain and in other areas of the shower floor. Administrator stated she has been trying to find a reasonable contractor to fix the shower floor and has been unsuccesful. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Deficiency is cited per Title 22 CA code of regulations and listed on LIC 9099D. Failure to submit proof of correction (POC) on or before POC due date and/or any repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted. Appeal rights and copy of this report emailed to administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rajind Basi
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
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-20210409095646
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: SANS SOUCI
FACILITY NUMBER: 075601574
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
1
2
3
4
5
6
7
Administrator agreed to fix the master bathroom shower flooring on or before the POC due date and submit to CCL proof of correction.
8
9
10
11
12
13
14
This requirement was not met as evidenced by broken shower flooring in the master bathroom which posed a potential health & safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Rajind Basi
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2