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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200595
Report Date: 04/10/2025
Date Signed: 04/10/2025 02:33:12 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
08/23/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220823112003
FACILITY NAME:LOVING HEART CARE HOMEFACILITY NUMBER:
079200595
ADMINISTRATOR:VAHID SANTOS, ELVIRAFACILITY TYPE:
740
ADDRESS:2652 CARSON WAYTELEPHONE:
(925) 948-5221
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 6DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marc Rico, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident developed pressure injuries while in care
Resident developed an infection requiring resident to be hospitalized
INVESTIGATION FINDINGS:
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On 04/10/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, Needs & services plans, centrally stored medication logs, hospital discharge summary 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: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 6
Control Number 15-AS-20220823112003
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: LOVING HEART CARE HOME
FACILITY NUMBER: 079200595
VISIT DATE: 04/10/2025
NARRATIVE
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Allegation: Resident developed pressure injuries while in care
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 06/06/22 with no pressure injuries. On 07/22/22, R1 was admitted to the hospital for generalized weakness. Review of hospital records show R1 had an unstageable pressure injury on her right buttock, a stage 2 pressure injury on her left heel, an inactive pressure injury on her right heel and an unstageable pressure injury on her coccyx. Hospital nurses provided wound care to R1’s pressure injuries. Interviews of facility staff and responsible parties and reviews of facility documents show R1 was neglected while residing at the facility. Staff (ADM, S1) gave inconsistent statements about R1’s pressure injuries. Staff denied having knowledge about the stages of R1’s pressure injuries but acknowledged that R1 did have a skin condition in the areas where the pressure injuries were located. Based on the department’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 resident developed pressure injuries while in care was found to be substantiated.

Allegation: Resident developed an infection requiring resident to be hospitalized
Investigation Finding: Substantiated
During investigation, the department reviewed resident’s (R1) medical records which showed R1 was hospitalized on 07/22/22 and diagnosed with various stages (stage 2, unstageable and inactive) of pressure injuries on R1. Interviews with facility staff and responsible parties, and review of facility documents showed facility failed to know about R1’s sustaining pressure injuries while in care. Facility staff failed to conduct body checks, document any changes in condition and provide proper care to R1. Based on the department’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 resident developed an infection requiring resident to be hospitalized was found to be substantiated.

Continued on next page, LIC 9099-C pg2
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20220823112003
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: LOVING HEART CARE HOME
FACILITY NUMBER: 079200595
VISIT DATE: 04/10/2025
NARRATIVE
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Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining pressure injuries while in care. Additional civil penalty determination is pending relating to serious bodily injuries.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

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

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20220823112003
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: LOVING HEART CARE HOME
FACILITY NUMBER: 079200595
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2025
Section Cited
CCR
87468.2(a)(4)
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Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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 in-service staff retraining certifications by a CCL approved vender on proper care and supervision of residents in compliance with Title 22 Section 87468.
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This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed an immediate health & safety risk to residents in care.
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Immediate civil penalty of $500 assessed during visit for serious bodily injury. Additional civil penalty determination is pending relating to this serious bodily injury.
Type A
04/12/2025
Section Cited
CCR
87466
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When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person…
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By POC due date, administrator agreed to complete and submit in-service staff retraining certifications by a CCL approved vender on proper care and supervision of residents in compliance with Title 22 Section 87466.
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This requirement was not met as evidenced by staff failing to address resident’s change in condition which posed an immediate 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: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
08/23/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220823112003

FACILITY NAME:LOVING HEART CARE HOMEFACILITY NUMBER:
079200595
ADMINISTRATOR:VAHID SANTOS, ELVIRAFACILITY TYPE:
740
ADDRESS:2652 CARSON WAYTELEPHONE:
(925) 948-5221
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 6DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marc Rico, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident's medication is missing
Facility did not ensure resident had an adequate amount of diapers
INVESTIGATION FINDINGS:
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5
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12
13
On 04/10/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, Needs & services plans, centrally stored medication logs, hospital discharge summary 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: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20220823112003
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: LOVING HEART CARE HOME
FACILITY NUMBER: 079200595
VISIT DATE: 04/10/2025
NARRATIVE
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Allegation: Resident’ s medication is missing
Investigation Finding: Unsubstantiated
During investigation, staff (S2) stated resident’s (R1) authorized representative was claiming she left a prescribed medication for R1 at the facility in July 2022. Staff denied receiving any prescribed medication from POA. S2 stated POA has the habit of taking R1’s medications, creams without letting staff know that she has taken them. S2 stated that POA was looking for R1’s cream on 07/23 -07/24, Triamcinolone Acetonide. Staff looked all over for it and could not find it. POA brought the cream back on 07/25/22. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident’s medication is missing and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that 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 resident’s medication is missing is unsubstantiated.

Allegation: Facility did not ensure resident had an adequate amount of diapers
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement show basic services do not include incontinent supplies. ADM stated R1 had an adequate amount of diapers and that they billed POA for R1’s incontinent supplies. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility did not ensure resident had an adequate amount of diapers and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that 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 facility did not ensure resident had an adequate amount of diapers 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: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6