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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200924
Report Date: 02/17/2026
Date Signed: 02/17/2026 12:54:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
02/11/2026 and conducted by Evaluator Andrew Christy
COMPLAINT CONTROL NUMBER: 15-AS-20260211103109
FACILITY NAME:A OHANA HOME FOR SENIORS, LLCFACILITY NUMBER:
079200924
ADMINISTRATOR:MALEKAMU, MARYFACILITY TYPE:
740
ADDRESS:1841 FLORENCE LNTELEPHONE:
(925) 698-1736
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 6DATE:
02/17/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary Mataele, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff did not ensure the facility maintained liability insurance
Staff did not safeguard resident personal belongings
INVESTIGATION FINDINGS:
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On 02/17/2026 at 11:00 AM, Licensing Program Analysts (LPAs) Andrew Christy and Ardalan Gharachorloo arrived unannounced to conduct 10-day initial complaint and deliver findings for the above allegations.LPA met with administrator Mary Mataele and explained the purpose of the visit.

During the course of the investigation, LPAs collected the following documents, including but not limited to: R1's inventory list (LIC 621), and expired copy of Liability Insurance.In addition, LPAs interviewed staff (S1) and reviewed 3 residents files (R1-R3).

Continued on LIC9099C.....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Andrew Christy
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026
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 3
Control Number 15-AS-20260211103109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: A OHANA HOME FOR SENIORS, LLC
FACILITY NUMBER: 079200924
VISIT DATE: 02/17/2026
NARRATIVE
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Continued from LIC9099.....

Allegation: Staff did not ensure the facility maintained liability insurance

The expired form of Liability Insurance shows that the policy lapsed on 08/04/2025 due to Non-payment. The preponderance of the evidence standard has been met, and therefore the allegation is SUBSTANTIATED.

Allegation: Staff did not safeguard resident personal belongings

LPAs interviewed S1 regarding the above allegation and about training in regards to belongings of residents no longer in the facility. S1 states that R1 passed away on 12/22/2025, and that W1 stated they would arrive later that week on 12/26/2025 to pick up the belongings. S1 stated that a caregiver (S2) was cleaning the room and threw away the belongings that were listed on LIC621. S1 stated that she understands that belongings need to be kept until picked up but S2 did not. LPAs also requested to view training logs for staff in regards to personal belongings of residents and did not see any training for that area. The preponderance of the evidence standard has been met, and therefore the allegation is SUBSTANTIATED.

Deficiencies are cited under the California Code of Regulations listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report, along with Appeal Rights, was provided to the administrator.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Andrew Christy
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20260211103109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: A OHANA HOME FOR SENIORS, LLC
FACILITY NUMBER: 079200924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2026
Section Cited
CCR
87217(j)
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Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded.

-This requirement is not met as evidenced by:
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On or before plan of correction due date, Licensee will submit proof to CCL that all caregivers have participated in an inservice/training on the handling of a resident's belongings.
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Based on record review and staff interviews, the resident's belongings were thrown away two days after the resident's passing.
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Type B
02/27/2026
Section Cited
HSC
1569.605
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On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000)...or neglect by, the licensee or its employees.
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Licensee shall submit the proof of renewed liability insurance to CCL by the POC date.
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-This requirement is not met as evidenced by:

Based on records review, the liability insurance was outdated.
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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: Andrew Christy
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3