011400627-8-22-2022-15-AS-KHOS-CHMRFH-20220825125910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011400627
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:29:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
08/03/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220803135529

FACILITY NAME:	ST. PAUL'S TOWERS		FACILITY NUMBER:	011400627
ADMINISTRATOR:	YUEN, CONNIE		FACILITY TYPE:	741
ADDRESS:	100 BAY PLACE		TELEPHONE:	(510) 835-4700
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	320	CENSUS: 226	DATE:	08/22/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Connie Yuen, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff assaulted resident.
Staff failed to provide resident's care needs.

INVESTIGATION FINDINGS:

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On 8/22/22 at 1:45pm, Licensing Program Analysts (LPAs) C. Lin and L. Fici conducted an unannounced subsequent complaint investigation regarding the above allegations and delivered investigation findings. LPAs explained the purpose of the visit with Administrator (AD).

Allegation: Staff assaulted resident – Unsubstantiated
The Department has investigated this allegation and per records reviews and interviews and found that assaulting resident was not witnessed by residents R2, R3 and staff members AD, S2 and S3. Both R2 and R3 have been living at facility for more than 15 years and have never witnessed any staff assaulted any resident.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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-20220803135529

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST. PAUL'S TOWERS	FACILITY NUMBER: 011400627
	VISIT DATE: 08/22/2022

NARRATIVE

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Allegation: Staff failed to provide resident's care needs – Unsubstantiated
The Department has investigated this allegation and per records reviews and interviews. The hospice notes indicated that hospice nurse W1 was with R1 between 1:56am and 4:50am on 8/3/2022. No care notes indicated that R1 asked for assistance of using oxygen after W1 left. No other hospice nurse visiting was recorded in the morning on 8/3/2022. R1's physician order of oxygen indicated that oxygen was a PRN prescription. R1 was an independent living resident in facility, staff stated that R1 knows how to call for assistance even when R1 was declining. Residents R2 and R3 stated that staff usually arrived to their rooms in 2 minutes each time when they pressed call button.

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

No deficiency cited. Exit interview conducted with Administrator and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC9099 (FAS) - (06/04)

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