079200977-5-23-2023-15-AS-YFLS-CSLLMP-20230608085303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200977
Report Date: 05/23/2023
Date Signed: 05/23/2023 06:15:58 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
03/22/2023 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230322104728

FACILITY NAME:	WE CARE ELDERLY CARE		FACILITY NUMBER:	079200977
ADMINISTRATOR:	WHITE, BRITTANY D		FACILITY TYPE:	740
ADDRESS:	4155 BELL AVE		TELEPHONE:	(510) 375-4460
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	8	CENSUS: 5	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Rosa Mayorga, Care Staff		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Licensee does not ensure there is a qualified Administrator present

INVESTIGATION FINDINGS:

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On 05/23/23 at 02:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a complaint investigation. Upon arrival, LPA met with Tenilius Hampton, Care Staff and explained the reason for the visit. Licensee Lurinza Bean and Administrator Brittany White (ADM) were both telephoned by Care Staff. ADM due to arrive in about 45 minutes. One (1) resident was present and one (1) staff. ADM arrived at 03:40 PM and had to departed around 5:00 PM.

During the course of the investigation, LPA toured the facility and requested the following documents: Client files with admission agreements, physician's reports, incident reports, ID/Emergency information, hospice and home health notes if applicable; Staff Files: Personnel Record (LIC 500), Staff Roster, Administrator's certificates for Administrator and Licensee.

...continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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 5

Control Number 15-AS-20230322104728

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: 05/23/2023

NARRATIVE

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...continued from LIC9099

Allegation: Licensee does not ensure there is a qualified Administrator present

Based on interviews with RP, LPA's record review of Personnel Report (LIC500) dated 10/08/21 and facility site visits on 03/30/23, 05/18/23 and 05/23/23, ADM was not present during the hours stated on the LIC500. LPA requested ADM to provide a current LIC500 on 03/30/23 & 05/18/13; to date on 05/23/23 the LIC500 was not provided, designated staff was not present, and LIC308 was last dated 11/01/21.

The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.
Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided to Rosa Mayorga, Care Staff.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20230322104728

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: 05/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2023 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator ...there shall be coverage by a designated substitute who shall have qualifications... -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ADM agreed be on the premises a sufficient number of hours, review regulation 87405, update LIC308, LIC500 and submit documents to CCLD by POC date.
	8 9 10 11 12 13 14	Based on observations, interviews & records, ADM did not comply with the section cited by not having qualified staff on site which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
03/22/2023 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230322104728

FACILITY NAME:	WE CARE ELDERLY CARE		FACILITY NUMBER:	079200977
ADMINISTRATOR:	WHITE, BRITTANY D		FACILITY TYPE:	740
ADDRESS:	4155 BELL AVE		TELEPHONE:	(510) 375-4460
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	8	CENSUS: 5	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Rose Mayorga, Care Staff		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Staff do not provide nutritious meals to residents
Staff do not ensure there is an adequate supply of food in the facility

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20230322104728

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: 05/23/2023

NARRATIVE

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...continued from LIC9099

Allegations:
Staff do not provide nutritious meals to residents
Staff do not ensure there is an adequate supply of food in the facility

LPA and S1 toured the kitchen while ground beef, rice, green beans and peas were being prepared for dinner. LPA further observed a breakfast, lunch, and dinner menu posted on the kitchen refrigerator. Meal serving times are about 8:00 AM, 12:00 PM, snacks throughout the day, about dinner is about 5:30 PM - 6:00 PM. S1 and S2 said snacks are always available. There was a variety of a 2-day supply of perishables, 7-day supply of non-perishable and frozen foods that consisted of chicken, pork, beef, turkey, milk, bread, yougurt, eggs, grapes, bananas, oranges, pears, crackers, pretzels, ice cream, popsicles, and condiments. Residents (R1, R2) stated that they have enough to eat. R1 and Witnesses (W2, W3) stated that the facility may want to provide a different variety of foods. LPA observed meal preparations taking place during cite visits on 03/30/23, 05/18/23 and 05/23/23, and had adequate amounts for all residents.

Based on LPA’s observations and interviews, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided to Rosa Mayorga, Care Staff.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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