<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600229
Report Date: 06/06/2024
Date Signed: 08/23/2024 03:51:17 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
12/21/2023 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20231221132552
FACILITY NAME:JASMINE'S CARE HOMEFACILITY NUMBER:
015600229
ADMINISTRATOR:MITCHELL, TRACYFACILITY TYPE:
735
ADDRESS:1042A CALCOT PLACETELEPHONE:
(510) 532-4556
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:8CENSUS: 1DATE:
06/06/2024
UNANNOUNCEDTIME BEGAN:
02:45 AM
MET WITH:Tracy Mitchell, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in a resident developing a pressure injury
Staff did not ensure a resident had timely medical appointments
Staff did not address a resident's change in medical condition
Staff did not prevent a resident from a fall while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/06/24* at 2:45 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver findings for the above allegations . LPA met with Tracy Mitchell, Administrator and explained the purpose of the visit.

During the course of investigation, the Department interviewed 2 facility staff (S1 and S2), 2 facility residents (R1 & R2) Highland Hospital Social Worker (W1), Highland Hospital Physician (W2), and Regional Center of the East Bay Associate Director (W3). R1’s medical records from Highland Hospital from 12/7/23 until his discharge on 1/5/24 were also reviewed.

Allegation: Staff neglect resulted in a resident developing a pressure injury

Finding: Substantiated

***report continues on LIC9099C***

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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 5
Control Number 15-AS-20231221132552
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: JASMINE'S CARE HOME
FACILITY NUMBER: 015600229
VISIT DATE: 06/06/2024
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
***report continues from LIC9099**

Highland Hospital medical records revealed that on 12/7/2023 R1 was transported from his care facility via ambulance with the chief complaint of sustaining a fall in the bathroom of the facility on 12/6/23. R1 was admitted and diagnosed with two stage three pressure injuries on his sacrum and left hip. R1 was not on hospice or receiving home health for his pressure injuries.

An interview with S1 revealed that she was aware that R1 had a pressure injury on his hip and buttock area observing the wounds while giving R1 a bath on 12/6/23. S1 stated that she felt she could manage the wound care for R1. R1 was not receiving wound care from anyone other than S1. S1 stated that R1’s pressure injuries developed on 12/7/2023. S1 denied that R1’s pressure injuries were in the condition that Highland Hospital documented and photographed from R1’s hospital visit on 12/7/2023. S2 denied seeing any marks on R1’s body while giving him a shower on 11/30/2023.

Allegation: Staff did not ensure a resident had timely medical appointments

Finding: Substantiated

Review of R1’s file revealed that R1 was last seen by his primary physician on 7/23/23. No other medical visits were made despite R1’s declining health. S1 stated during the initial 10-day visit that she did not notify anyone or do anything about the resident’s decline. She stated, “I waited too long” and “I should have done something more” and other similar statements.

Allegation: Staff did not address a resident's change in medical condition

Finding: Substantiated

An interview with S1 revealed that she was aware of R1’s declining health over the past 5 years but did not take R1 to any medical appointments during that time with the exception of his yearly physical. During his yearly physical S1 did not bring up her concerns about R1’s declining health to his PCP.

***report continues on LIC9099C***
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20231221132552
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: JASMINE'S CARE HOME
FACILITY NUMBER: 015600229
VISIT DATE: 06/06/2024
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
***report continues from LIC9099C***

Allegation: Staff did not prevent a resident from a fall while in care

Finding: Substantiated

Highland Hospital medical records revealed that on 12/7/2023, R1 was diagnosed with a small subarachnoid hemorrhage, C5 fracture, and posterior ligamentous injury posterior C3 to C5. R1 was reported as falling at the facility on 12/6/2023 and transported to Highland Hospital on 12/7/2023.

An interview with S1 revealed that R1 fell while going to the restroom on 12/6/2023. S1 stated that R1 would fall once or twice a week and would get back up. S1 did not have a fall plan in place for R1. S1 admitted to noticing R1 experiencing a decline in his condition within the last five years ranging from urinating on himself to falling regularly. S1 acknowledged that R1 was having to use the walls to ensure that he would not fall. S1 admitted to keeping R1 at Jasmine’s Care Home regardless of R1’s noticeable decline in health.

The Department has investigated the complaint alleging staff neglect resulted in a resident developing a pressure injury, staff did not ensure a resident had timely medical appointments, staff did not address a resident's change in medical condition and staff did not prevent a resident from a fall while in care. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

Exit interview conducted, a copy of this report and appeal rights provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20231221132552
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: JASMINE'S CARE HOME
FACILITY NUMBER: 015600229
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
85075.4
1
2
3
4
5
6
7
85075.4 Observation of the Client
(b) The licensee shall provide assistance when observation reveals needs which might require a change in the existing level of service, or possible discharge or transfer to another type of facility.
1
2
3
4
5
6
7
Licensee will develop a plan to monitor residents from pressure injuries (ie: daily documented body checks) and submit the plan to CCL by POC date.
8
9
10
11
12
13
14
Based on reports the licensee did not comply with the section cited above. Resident sustained a presure injury while in care which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
06/28/2024
Section Cited
CCR
85075
1
2
3
4
5
6
7
85075 Health-Related Services

(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
1
2
3
4
5
6
7
Licensee will document that residents recieve routine medical visits and submit visi logs to CCL semi-annually to CCL by POC date.
8
9
10
11
12
13
14
Based on reports the licensee did not comply with the section cited above. Licensee did not ensure that resident was recieving care to meet their medical needs which poses an immediate health, safety or personal rights risk to persons 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20231221132552
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: JASMINE'S CARE HOME
FACILITY NUMBER: 015600229
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
85075.4
1
2
3
4
5
6
7
85075.4 Observation of the Client
(c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any.

1
2
3
4
5
6
7
Licensee will develop a plan to monitor residents for changes in medical condition and submit the plan to CCL by POC date.
8
9
10
11
12
13
14
Based on reports the licensee did not comply with the section cited above. Licensee did not address the residents change in condition which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
06/28/2024
Section Cited
CCR
80078
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
1
2
3
4
5
6
7
Licensee will develop a plan to monitor and mitigate residents risk of falls and submit the plan to CCL by POC date.
8
9
10
11
12
13
14
Based on reports the licensee did not comply with the section cited above. Licensee did not address the residents falls in a timely manner which poses an immediate health, safety or personal rights risk to persons 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5