015600382-2-1-2023-15-AS-BFOG-CR4SBN-20230421134411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600382
Report Date: 02/01/2023
Date Signed: 02/01/2023 06:40:25 PM

Unsubstantiated

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
08/21/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200821153620

FACILITY NAME:	GOD'S GRACE		FACILITY NUMBER:	015600382
ADMINISTRATOR:	RYAN JASON CARVAJAL		FACILITY TYPE:	735
ADDRESS:	629 HAMPTON ROAD		TELEPHONE:	(510) 278-3607
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	23	CENSUS: 19	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Susan Martinez/Licensee. and Joseph Crisol/Administrator		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Staff’s neglect led to residents’ death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Susan Martinez, licensee, and Joseph Crisol, administrator, and informed the purpose of visit.

It was alleged that residents are being rushed during mealtime which has caused two residents, R1 and R2, to pass away from choking.

During the course of investigation, LPA reviewed residents’ records and Coroner’s Reports, and obtained copies of documents. LPA conducted health and safety inspection on 8/25/20. LPA interviewed staff (S1, S2 and S3) on 1/30/20 and 12/20/22, and residents (R3, R4. R5, R6. R7, R8. R9. R10, R11, R12) on 12/20/22, and resident’s family members (FM2 and FM22) on 12/19/22 and 1/09/23.

.....continied on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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-20200821153620

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: GOD'S GRACE	FACILITY NUMBER: 015600382
	VISIT DATE: 02/01/2023

NARRATIVE

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Although Coroner’s Reports indicated asphyxia due to aspiration of food and probable asphyxia due to obstruction of larynx by food bolus as cause of death for R1 and R2 respectively, 9 out of 10 residents indicated staff do not rush them when eating. LPA was unable to obtain information from one of the residents

All 3 staff interviewed denied rushing the residents when eating. All 3 staff stated R1 was eating when R1 choked, Staff performed Heimlich maneuver and called 9-1-1 immediately. R2 was done eating when R2 fell. R2 didn’t show signs of choking when the incident happened. Staff acted accordingly by performing CPR and called 9-1-1. R1 and R2 were pronounced dead on the scene. FM2 was aware of R2’s incident but was not able to provide information. FM22 stated he has visited R2 at the facility, and didn’t observe any signs of abuse or neglect, and felt the staff are very caring and kind.

Information obtained from staff that R1 and R2 can feed selves were consistent with the Physician’s Reports. FM22 also stated R2 can eat on his own.

Based on LPA’s interviews, records and documents review, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited,

Exit interview conducted, and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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