015600507-5-27-2021-15-AS-KHOS-C4VMVZ-20210713095734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600507
Report Date: 05/27/2021
Date Signed: 05/27/2021 10:58:19 AM

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
01/07/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200107113629

FACILITY NAME:	C & R HOME FOR THE ELDERLY		FACILITY NUMBER:	015600507
ADMINISTRATOR:	TEOFILO CRIS SANQUE		FACILITY TYPE:	740
ADDRESS:	34819 CLOVER STREET		TELEPHONE:	(510) 324-0627
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Janet Dimayuga/Staff		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Neglect resulting in resident (R1) sustaining laceration, bleeding and swelling.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to delver the findings on the above allegation. LPA met with Janet Dimayuga, staff, and informed the purpose of visit.

During the course of investigation, LPA obtained copies of resident roster, staff schedule and resident’s (R1) documents. LPA reviewed residents' records and conducted interviews.

LPA interviewed residents (R1, R2, R3, R4 and R5) who all indicated staff treat them good and attends to them when needed. R2, R3, R4 and R5 did not observe anyone physically and/or sexually abusing R1 which LPA confirmed with R1.

.....continued next page (9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

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-20200107113629

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: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
	VISIT DATE: 05/27/2021

NARRATIVE

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Staff S2 stated she was on duty and the one who observed R1 bleeding. Ambulance was called immediately and R1 was sent out to the hospital which collaborated with S1’s statement. S1 and S2 indicated R1 was on blood thinner.

Review of hospital discharge summary revealed problem lists were urethral bleeding, vaginal bleeding and hypertension. LPA interviewed the hospitalist (H2) who attended to R1. H2 indicated R1 has urethral bleeding and laceration when admitted which could be self-inflicted injuries and emphasized that the bleeding was not a vaginal bleeding. Information obtained from R1’s family member and Power of Attorney (FM1) confirmed R1 had bleeding but the bleeding was coming from bladder due mass and blood thinner. FM1 indicated there was no abuse nor R1 was neglected by the staff.

Based on all the information gathered, the allegation of neglect resulting in R1 sustaining laceration, bleeding and swelling is closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or without a reasonable basis; therefore, the complaint is dismissed.

Exit interview conducted. Copy of this report provided to Janet Dimayuga.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC9099 (FAS) - (06/04)

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