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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201161
Report Date: 04/04/2023
Date Signed: 04/04/2023 02:06:14 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
03/29/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230329133115
FACILITY NAME:WALNUT CREEK CARE HOMEFACILITY NUMBER:
079201161
ADMINISTRATOR:JAIN, ASHAFACILITY TYPE:
740
ADDRESS:2562 VENADO CAMINOTELEPHONE:
(925) 287-8994
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
04/04/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver Nestor AvecillaTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure that resident's medication were stored in the container they were originally received in.
INVESTIGATION FINDINGS:
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On 04/04/2023 at 10:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to inspect facility concerning the allegation above. LPA explained purpose of the visit to Caregiver Nestor Avecilla who then reported the allegation to the Licensee Asha Jain by phone.

At 10:45 AM, Staff S3 opened the locked medication cabinet for LPA who confirmed that the medications were not being stored in their original container, a practice confirmed by staff S1, S2, and S3. Based on staff interview and LPA observation, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED.

Deficiency cited per Title 22 California Code of Regulations is listed on the LIC9099-D. 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 via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
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 2
Control Number 15-AS-20230329133115
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: WALNUT CREEK CARE HOME
FACILITY NUMBER: 079201161
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2023
Section Cited
CCR
87465(h)(5)
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87465 Incidental Medical and Dental Care (h) The following ... shall apply ... (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement was not met as evidenced by:
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During visit, resident medications were all removed from pill boxes and returned to original containers.
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Based on LPA J Sampair's 10:45 AM observation and staff confirmation of 3 out of 3 resident's medications being stored outside of their original container, which poses an immediate Health, Safety or Personal Rights 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: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2