079200924-6-5-2025-15-AS-HHUL-DHQVV7-20250617164552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200924
Report Date: 05/15/2025
Date Signed: 06/05/2025 05:15:08 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
05/14/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20250514133236

FACILITY NAME:	A OHANA HOME FOR SENIORS, LLC		FACILITY NUMBER:	079200924
ADMINISTRATOR:	MALEKAMU, MARY		FACILITY TYPE:	740
ADDRESS:	1841 FLORENCE LN		TELEPHONE:	(925) 698-1736
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 4	DATE:	05/15/2025
		UNANNOUNCED	TIME BEGAN:	04:39 PM
MET WITH:	Mary Rose Malekamu Mataele, Administrator		TIME COMPLETED:	06:40 PM

ALLEGATION(S):

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Personal rights x 1

INVESTIGATION FINDINGS:

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On 06/05/25 at 5PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to amend the complaint delivered on 05/15/25. LPA explained the purpose of the visit with ADM.

During investigation, LPA obtained the following documents from ADM: Resident roster, Staff roster (LIC 500), R1's admission agreement, Needs & Services Plan, Physician's report, centrally stored medication logs, incident 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: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

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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Control Number 15-AS-20250514133236

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 OHANA HOME FOR SENIORS, LLC	FACILITY NUMBER: 079200924
	VISIT DATE: 05/15/2025

NARRATIVE

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Allegation: Resident subjected to physical abuse while in care
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed resident’s responsible party (POA), resident (R2), staff (ADM, S1) and reviewed resident’s (R1) documents. Review of R1’s admission agreement showed R1 was first admitted at the facility on 02/25/25. R1’s physician’s report dated 02/23/25 showed his primary diagnosis as acute exacerbation of COPD community acquired pneumonia with a secondary diagnosis of severe alcohol use disorder with alcohol intoxication. LPA interviewed S1 who stated that on 04/25/25 at around 7PM, he witnessed R1 drunk and was being verbally and physically aggressive towards another resident who is the grandmother of the licensee. S1 stated R1 moved his wheelchair aggressively towards R2, side swiping and breaking a bunch of side table decorations which caused bruising on his upper left arm. S1 stated R2 then kicked the kitchen half door with his leg punching a large hole in the middle. LPA interviewed R2 who stated she defended herself by striking him with a thin bamboo back scratcher on his shoulder. ADM stated staff called the police who arrived around 7:30PM, conducted a health check, interviewed residents (R1, R2) and did not file a report when they found out that R1 was drunk and was verbally and physically abusive towards another elderly resident who is the grandmother of the licensee. On 05/30/25 at 9:30AM, LPA interviewed R1’s responsible party (POA) who stated that on 05/14/25, R1 called 911 and was taken by ambulance to the hospital. He claimed physical abuse while in care and refused to go back to the facility. POA stated R1 was safely relocated to another elderly facility in Livermore on 05/19/25. 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 was subjected to physical abuse while in care is unsubstantiated.

No deficiencies cited. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

LIC9099 (FAS) - (06/04)

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