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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201105
Report Date: 03/27/2025
Date Signed: 03/27/2025 04:24:22 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
03/25/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250325090010
FACILITY NAME:CARING HEARTS ELDERLY HOMEFACILITY NUMBER:
079201105
ADMINISTRATOR:SANTOS VAHID, ELVIRAFACILITY TYPE:
740
ADDRESS:3498 SWALLOW COURTTELEPHONE:
(925) 948-5221
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 5DATE:
03/27/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mylene Ugaban, Staff
Elvira Vahid, Administrator		TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident eloped due to lack of care or supervision from staff
INVESTIGATION FINDINGS:
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On 03/27/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (S3) and spoke with administrator (ADM) on the phone who authorized S3 to act on her behalf and sign the reports. LPA gathered information on the allegations and delivered investigation finding to S3. LPA explained the purpose of the visit with ADM and S3.

During investigation, the department obtained the following documents from administrator – personnel record (LIC500), residents’ roster, admission agreement, physician's report, re-appraisals and incident report.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
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 3
Control Number 15-AS-20250325090010
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: CARING HEARTS ELDERLY HOME
FACILITY NUMBER: 079201105
VISIT DATE: 03/27/2025
NARRATIVE
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ALLEGATION: Resident eloped due to lack of supervision from staff
INVESTIGATION FINDING: Substantiated
During investigation, the department conducted interviews of facility staff (S1, S2), reporting party (RP) and reviewed resident (R1) documents. On 03/24/25, LPA interviewed reporting party (RP) who stated that a neighbor approached him on 03/23/25 around 02:14PM and informed him that a resident (R1) knocked on their door and told them to contact the police because her home is being invaded. RP stated that it was known to the neighbors that the facility cares for elderly residents. The neighbor walked over to the care home and explained the situation with staff (S1, S2) who were completely unaware that anyone from the facility was missing or has left the home. LPA interviewed S1 who confirmed that they did not know that R1 left the facility on 03/23/25 until the neighbor knocked on the door and told them R1 was at his home. RP stated the neighbor brought R1 safely back to the facility around 3PM. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that resident eloped due to lack of supervision from staff. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250325090010
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: CARING HEARTS ELDERLY HOME
FACILITY NUMBER: 079201105
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2025
Section Cited
CCR
87468.2(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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By POC due date, ADM agrees to complete and submit in-service staff retraining certifications on residents’ personal rights in compliance with Section 87468.2 (a)(4).
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This requirement was not met as evidenced by neglect/lack of supervision of resident that eloped without their knowledge which posed a potential health & safety risk to residents 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3