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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200977
Report Date: 07/14/2021
Date Signed: 07/14/2021 05:41:35 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
07/23/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200723103937
FACILITY NAME:WE CARE ELDERLY CAREFACILITY NUMBER:
079200977
ADMINISTRATOR:BEAN, LURINZAFACILITY TYPE:
740
ADDRESS:4155 BELL AVETELEPHONE:
(510) 375-4460
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:6CENSUS: 5DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Lurinza Manning, AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
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Facility staff yelled at resident
INVESTIGATION FINDINGS:
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On 7/14/2021 at 4:25PM, Licensnig Program Analytst (LPAs), L. Hall and C. Fowler arrived unannounced to conduct complaint investigation and deliver findings for the above allegation. LPAs met with Administrator, Lurinze Manning and explained the reason for the visit.

During the course of the investigation, LPA interviewed two (2) Staff. Staff confirmed there was an argument between S3 and R1. LPAs requested a copy of the staff roster, resident roster, and incident report to be sent to LPA.

Based on interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC 9099D.

Continued on LIC9099C.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 3
Control Number 15-AS-20200723103937
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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited
CCR
87468.1(a)(1)
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87468.1 (a) Residents... shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff... This requirement was not met as evidence by:
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Administrator agreed to have an in-service training on personal rights and submit proof of training to CCLD by POC date.
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Based on LPAs interviews licensee did not comply with the section cited above which poses a potential health and safety risk to 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: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20200723103937
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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
VISIT DATE: 07/14/2021
NARRATIVE
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Continued from LIC9099.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3