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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 01:13:40 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
08/06/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240806132429
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:
11:30 AM
MET WITH:Paul Henry, Administartor TIME COMPLETED:
01:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left resident on the commode for an extended period of time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/15/2025 a 11:30AM, Licensing Program Analysts (LPAs), T. Syess-Gibson and C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Paul Henry, Administrator and explained the reason for the visit.


During the visit, the Department conducted interviews with staff, residents, witnesses, and the complainant. LPA obtained and reviewed records such as staff schedule, (LIC500) employee work schedules and contact information, Medication Administrator Records (MAR), Appraisal Needs and Services (ANS), Shift Log (daily notes), LIC602 , Unusual Incident Reports (UIRs) and daily check off Sheet for residents from 08/01/2024- 08/13/2024 and ADL's Checklist.

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 4
Control Number 15-AS-20240806132429
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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14
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18
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20
21
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32
Continued from LIC9099


Staff left resident on the commode for an extended period of time

During the course of the investigation, the Department interviewed residents and staff. Interview with R1 stated she placed on the commode for almost three hours. R1 stated she pressed the call button, no one came for hours. Interview with R2 indicated, when she presses the call button for assistance after using the commode, staff responds between five and ten minutes. Interviews with staff S1, S2 and S3 indicated residents who are nonverbal are checked on between five to ten minutes when on the commode. Residents who are verbal, will press the call button or call our names for assistance. 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. S2 stated she placed R1 on the commode and noticed another resident started walking towards the front door, thinking someone was ringing the doorbell, the ringing sound was coming from call button R1 pressed. Interview with S1 revealed, S1 reviewed surveillance recording and denied seeing anyone near the front door.

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.

LPA already cited (87468.1 (a) (3)) on complaint number (15-AS-20240806132429)

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D on complaint number (15-AS-20240806132429) . Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and 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: 2 of 4
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
08/06/2024 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240806132429

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:
11:30 AM
MET WITH:Paul Henry, AdministratorTIME COMPLETED:
01:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/15/2025 a 11:40AM, Licensing Program Analysts (LPAs), T. Syess-Gibson and C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Paul Henry, Administrator and explained the reason for the visit.


During the visit, the Department conducted interviews with staff, residents, witnesses, and the complainant. LPA obtained and reviewed records such as staff schedule, (LIC500) employee work schedules and contact information, Medication Administrator Records (MAR), Appraisal Needs and Services (ANS), Shift Log (daily notes), LIC602 , Unusual Incident Reports (UIRs) and daily check off Sheet for residents from 08/01/2024- 08/13/2024 and ADL's Checklist.

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: 3 of 4
Control Number 15-AS-20240806132429
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099A


Staff mismanaged resident medication

During the course of the investigation, LPA observed the medication in a locked cabinet, located in the kitchen. LPA reviewed residents R1, R3 and R5 physician’s reports and facility’s medication administration record (MAR). LPA observed medications were administered correctly.

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: 4 of 4