079200921-12-22-2021-15-AS-KHOS-CA4N53-20211227090851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200921
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:01:58 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
04/08/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200408090331

FACILITY NAME:	A FAMILY OF CARE		FACILITY NUMBER:	079200921
ADMINISTRATOR:	TAYLOR, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	1945 ST MARTIN PLACE		TELEPHONE:	(510) 755-7810
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 6	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Kathleen Taylor, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff member failed to fulfill mandated reporter responsibilities

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/22/2021 at 12:30PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator, Kathleen Taylor.

During the course of the investigation, LPA Y. Flores-Larios obtained and reviewed documents, interviewed staff and witness. On the allegation staff member failed to fulfill mandated reporter responsibilities. Staff 1 (S1) was not able to obtain an updated physician’s report prior to Resident 1 (R1’s) admission on 02/25/2020. Witness 2 (W2) had tried to get an appointment for R1, but due to COVID restrictions no patients were being seen for non-emergencies. S1 did compose a preplacement appraisal on 2/25/2020 and an appraisal needs and services on 2/27/2020.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20200408090331

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: A FAMILY OF CARE	FACILITY NUMBER: 079200921
	VISIT DATE: 12/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099.

S1 had taken R1 to the emergency room on 2/26/2020. At the time of the emergency visit documentation from the physician did not suggest any suspicion of abuse or neglect. On 2/28/2020, Witness 3 (W3) examined R1 and there was not any mention of abuse or neglect.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2