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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 08/06/2025
Date Signed: 08/06/2025 01:12:42 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
06/11/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250611163220
FACILITY NAME:TODOS SANTOS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
079200855
ADMINISTRATOR:CLAWSON, DAVID JFACILITY TYPE:
740
ADDRESS:1081 MOHR LNTELEPHONE:
(925) 798-3900
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:160CENSUS: 132DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:David Clawson, Director TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff mishandled a resident's medication
INVESTIGATION FINDINGS:
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On 08/06/2025 at 09:55 AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson.

On the allegation:Staff mishandled a resident's medication;Based on records review of the the Centrally Stored Medication Destructions Records; Medication Administration Records and care notes, R1's medication refills were not ordered prior to R1 running out of medication.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
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 2
Control Number 15-AS-20250611163220
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: TODOS SANTOS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 079200855
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by:
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Executive Director has agreed to create a new procedure for medication refills and conduct training for staff. ED will submit new procedure and staff sign in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not obtaining medication refills in a timely manner which poses a potential health and safety risk to the persons 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2