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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201044
Report Date: 05/15/2025
Date Signed: 05/15/2025 01:10:43 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
09/03/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240903092754
FACILITY NAME:DEER RIDGE COUNTRY VILLAFACILITY NUMBER:
079201044
ADMINISTRATOR:SALAZAR, HENRYFACILITY TYPE:
740
ADDRESS:419 DEL MONTE COURTTELEPHONE:
(925) 997-7354
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Kimberly Whittle, CargiverTIME COMPLETED:
01:28 PM
ALLEGATION(S):
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Resident fell sustaining a fracture due to staff neglect
Staff left resident in soiled bedding for an extended period of time
Staff left resident in soiled diapers for an extended period of time
INVESTIGATION FINDINGS:
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On 05/15/2025 at 9:56AM, Licensing Program Analysts (LPAs), T. Syess-Gibson and C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Kimberley Whittle, Caregiver. Kimberley contacted Paul Henry the Administrator. Administrator, Paul Henry, arrived at 10:23AM and LPAs and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, and the complainant. The Department also reviewed various records related to Resident (R1), including but not limited to R1's physician reports, pre-placement appraisals, background care information, the appraisal needs and services plan, progress notes, medication lists, activities of daily living (ADLs) charting forms, and shift responsibility checklists. Additionally, medical records from the hospital were obtained and reviewed. The facility's client roster and staff schedule were also collected and examined.

Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
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)
Page: 1 of 8
Control Number 15-AS-20240903092754
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: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
VISIT DATE: 05/15/2025
NARRATIVE
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Continued from LIC9099


Resident fell sustaining a fracture due to staff neglect

During the course of the investigation, R1’s medical records indicated that she was admitted to the hospital on August 3, 2024, due to pain in her left shoulder from a fall. She was discharged on August 7, 2024, with a diagnosis of a scapular fracture in her left shoulder. On August 11, 2024, R1 was re-admitted to the hospital for pain in her left shoulder following another fall, with the same diagnosis of scapula fracture. R1’s physician's report, dated May 21, 2024, did not indicate a diagnosis of dementia. According to R1’s Appraisal Needs and Service Plan, she requires assistance with ambulation and transfers to and from the bathroom; this was especially important at night. Interviews with R1 and staff revealed that S2 was the only staff member on duty during the overnight shift when the incidents occurred. R1 stated that S2 placed her on the commode and left her there for an extended period. S2 explained that during the time R1 was on the commode, she had to assist two other residents.


Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code are being cited on the attached LIC809D.

A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. A formal conference with CCLD will be scheduled at a later time.

Continue on LIC9099C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
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)
Page: 2 of 8
Control Number 15-AS-20240903092754
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: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
VISIT DATE: 05/15/2025
NARRATIVE
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Continued from LIC9099C


Staff left resident in soiled bedding for an extended period of time

During the course of the investigation, the Department Interviewed residents and staff. Interview with R1 stated she pressed the call button, no one came for hours. R1 stated she was left in soiled briefs, bed, and staff did not attend to her timely. During the interview, S2 stated she placed R1 on the commode while changing R1’s bedding, another resident started walking towards the front door thinking someone was ringing the doorbell. S2 went to re direct the other resident and put her back to bed. During the interview with S1, S1 stated the surveillance camera mounted in the main living area, displayed the kitchen, dining room, living room and hallway up to the table near front door. S1 reviewed the facility’s camera recordings and denied seeing anyone near the front door area, S1 did observe S2 eating, drinking, watching television and scrolling on her phone, when she watched the camera recording. S1 also stated during interview, S2 and R1 did not get along. S1 has been the mediator between the two of them over the telephone a couple of times.

Based on LPA's information obtained during investigation, 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 LIC9099D.



Continued on LIC9099C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
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)
Page: 3 of 8
Control Number 15-AS-20240903092754
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: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
VISIT DATE: 05/15/2025
NARRATIVE
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Continued from LIC9099C


Staff left resident in soiled diapers for an extended period of time

During the course of the investigation, the Department interviewed residents and staff. Interview with R1 stated she was left in soiled briefs, pressed the call button and staff did not attend to her timely. Interview with R2 indicated, when she presses the call button for assistance after having an accident in bed, staff responds between five and ten minutes. Interviews with staff S1, S2 and S3 indicated residents are checked every thirty minutes and after each meal for residents who are nonverbal and doesn’t use the call button. Residents who are verbal, will notify staff when they need assistance by telling staff or using the call button, S1 stated during interview, S2 and R1 did not get along. S1 has been the mediator between the two of them over the telephone a couple of times. Interview with S2 stated she placed R1 on the commode while changing R1’s bedding, another resident started walking towards the front door thinking someone was ringing the doorbell. During the interview with S1, S1 stated the surveillance camera mounted in the main living area, displayed the kitchen, dining room, living room and hallway up to the table near front door S1 reviewed the facility’s camera recordings and denied seeing anyone near the front door area,

Based on LPA's information obtained during investigation, 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 LIC9099D.




Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
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)
Page: 4 of 8
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
09/03/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240903092754

FACILITY NAME:DEER RIDGE COUNTRY VILLAFACILITY NUMBER:
079201044
ADMINISTRATOR:SALAZAR, HENRYFACILITY TYPE:
740
ADDRESS:419 DEL MONTE COURTTELEPHONE:
(925) 997-7354
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Kimberly Whittle, CargiverTIME COMPLETED:
01:28 PM
ALLEGATION(S):
1
2
3
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9
Staff do not treat resident with dignity and respect
Staff did not provide resident's authorized representative with resident's records
INVESTIGATION FINDINGS:
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On 05/15/2025 at 9:56AM, Licensing Program Analysts (LPAs), T. Syess-Gibson and C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Kimberley Whittle, Caregiver. Kimberley contacted Paul Henry the Administrator. Administrator, Paul Henry, arrived at 10:23AM and LPAs and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, and the complainant. The Department also reviewed various records related to Resident (R1), including but not limited to R1's physician reports, pre-placement appraisals, background care information, the appraisal needs and services plan, progress notes, medication lists, activities of daily living (ADLs) charting forms, and shift responsibility checklists. Additionally, medical records from the hospital were obtained and reviewed. The facility's client roster and staff schedule were also collected and examined.

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
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)
Page: 5 of 8
Control Number 15-AS-20240903092754
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: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
VISIT DATE: 05/15/2025
NARRATIVE
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Continued from LIC9099C

Staff do not treat resident with dignity and respect

During the course of the investigation, the Department interviewed residents and staff. Interview with R1 indicated some of the staff were respectful, and there were some not so much. Interviews with R2, S1, S2 and S3 indicated staff treats residents with respect and dignity and has not witnessed any disrespect towards the residents in care. S1 also, indicated treating residents with respect is one of the facility’s requirements before hire and is also part of staff’s onboard training.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Staff did not provide resident's authorized representative with resident's records

During the course of the investigation, the Department interviewed Administrator (ADM). ADM stated during interview, facility provides residents record information to family members, conservator or responsible person (RP), as long as the documents requested does not have any other resident’s information on the documents. ADM provided LPA with emails to R1’s family members of requested documents/records, LPA observed during records review the requested documents were submitted to R1’s family members.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.


No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
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)
Page: 6 of 8
Control Number 15-AS-20240903092754
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: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2025
Section Cited
HSC
1569..269
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§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect, financial exploitation.....

This requiremnet is not met by evidenced by:
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Administrator has agreed to use a department approved vendor to re-train all staff regarding fall risk prevention and submit training materials and staff sign sheet to CCLD by POC date.

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Based on investigation, licensee did not comply with the section cited above resulting in R1 sustaining a scapula fracture to the left shoulder which poses an immediate health and safety risk to the persons in care.
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A formal conference with CCLD will be scheduled at a later time.

$500.00 immediate civil penalty is assessed.
Type B
05/25/2025
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions... (3)Ensuring that incontinent residents...

This requiremnet is not met by evidenced by:
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Administrator has agreed to use a department approved vendor to re-train all staff regarding proper care for residents who has a manageable bowel/bladder incontinence condition and submit training materials and staff sign sheet to CCLD by POC date.
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Based on interviews, the Licensee did not comply with the section cited above by having R1 in a soiled bed for a long period of time which posed a potential health and safety risk and personal rights risk to persons in care
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Administrator has agreed to use a department approved vendor to re-train all staff regarding proper care for residents who has a manageable bowel/bladder incontinence condition and submit training materials and staff sign sheet to CCLD by POC date.
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: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 15-AS-20240903092754
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: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1 (a) (3) (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)To be free from punishment, humiliation...

This requirement is not met as evidenced by:
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Administrator has agreed to use a department approved vendor to re-train all staff regarding proper care for residents who has a manageable bowel/bladder incontinence condition and submit training materials and staff sign sheet to CCLD by POC date.
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Based on interviews, the Licensee did not comply with the section cited above by having R1 in a soiled breifs for a long period of time which posed a potential health and safety risk and personal rights 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: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8