079201249-7-3-2025-15-AS-KHOS-DJENZD-20250709105409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 07/03/2025
Date Signed: 07/03/2025 04:13:26 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
05/28/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20250528222146

FACILITY NAME:	DELTA SHORES ASSISTED LIVIMG		FACILITY NUMBER:	079201249
ADMINISTRATOR:	DAVID CLAWSON		FACILITY TYPE:	740
ADDRESS:	825 E 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 49	DATE:	07/03/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jared Pickard, Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff inappropriately pushed a resident while in care
Staff inappropriately restrained a resident while in care

INVESTIGATION FINDINGS:

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On 07/03/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (ED, S1), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with staff.

During investigation, LPA obtained the following documents from executive director – Personnel record (LIC500), Residents roster, admission agreement, reappraisals, needs & services plan, physician's report, centrally stored medication logs, medication administration records, incident reports.

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: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250528222146

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: DELTA SHORES ASSISTED LIVIMG	FACILITY NUMBER: 079201249
	VISIT DATE: 07/03/2025

NARRATIVE

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Allegation: Staff inappropriately pushed a resident while in care
Investigation Finding: Substantiated
During investigation, LPA conducted interviews with, reporting party (RP), third party witness (W1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. Review of R1’s records showed he was first admitted at the facility on 02/28/24. R1 was assessed as having dementia, non-ambulatory and needs total assistance with bathing, dressing and behavioral expressions. LPA interviewed ED and W1 who confirmed that the incident occurred on 05/20 at 2PM wherein staff (S2) inappropriately pushed R1 against a wall while in care and that S2 was written up by ED. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Allegation: Staff inappropriately restrained a resident while in care
Investigation Finding: Substantiated
During investigation, LPA conducted interviews with, reporting party (RP), third party witness (W1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. RP and W1 stated that on 05/20/25 at 2PM, staff (S2) inappropriately restrained R1 by holding him against a wall. ED confirmed with LPA that staff (S2) was internally investigated and was written up for inappropriately restraining R1. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates 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: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250528222146

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: DELTA SHORES ASSISTED LIVIMG	FACILITY NUMBER: 079201249
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/03/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/25/2025 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.	1 2 3 4 5 6 7	By POC due date, ED agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on proper redirecting of resident in compliance with Section 87468.1(a)(3).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff inappropriately pushing resident which posed a potential health & safety risk to resident in care	8 9 10 11 12 13 14
Type B 07/25/2025 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	To be accorded dignity in their personal relationships with staff, residents, and other persons	1 2 3 4 5 6 7	By POC due date, ED agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on personal rights of resident in compliance with Section 87468.1(a)(1).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff inappropriately restraining a resident which posed a potential health & safety risk to resident in care.	8 9 10 11 12 13 14

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: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC9099 (FAS) - (06/04)

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